CERTIFICATE OF INSURANCE Humana Insurance Company · EMPLOYER: FLOYD COUNTY GOVERNMENT GROUP NUMBER: 671728 CERTIFICATE OF INSURANCE Humana Insurance Company This Certificate is not

GN-70051-07 EM COVER

L C EMPLOYER: FLOYD COUNTY GOVERNMENT

GROUP NUMBER: 671728

CERTIFICATE OF INSURANCE

Humana Insurance Company

This Certificate is not an insurance policy. It is an outline of the insurance provided by the group policy and it does not extend or change the coverage afforded by such group policy. The insurance described by this Certificate is subject to all the provisions, terms, exclusions and conditions of the group policy. This Certificate supersedes and replaces any Certificate previously issued under the provisions of the group policy.

Bruce Broussard President

TABLE OF CONTENTS

GN-70051-07 EM TAB

POLICYHOLDER (EMPLOYER): FLOYD COUNTY GOVERNMENT GROUP NUMBER: 671728 BENEFITS EFFECTIVE DATE Employee Voluntary Life for Employee 01/01/2018 Employee Voluntary AD&D for Employee 01/01/2018 Dependent Voluntary Life for Employee & Covered Dependent 01/01/2018 Dependent Voluntary Life for Employee & Covered Spouse 01/01/2018 Spouse Voluntary AD&D for Employee & Covered Spouse 01/01/2018 SCHEDULE OF BENEFITS DEFINITIONS ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE TERMINATION OF COVERAGE EMPLOYEE TERM LIFE INSURANCE BENEFITS WAIVER OF PREMIUM ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR COVERED EMPLOYEES ACCELERATED BENEFITS GENERAL PROVISIONS DEPENDENT TERM LIFE INSURANCE BENEFITS ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR COVERED DEPENDENT SPOUSE PORTABILITY PRIVILEGE DISCOUNT DISCLOSURE SPLIT BILL AMENDMENT

SCHEDULE OF BENEFITS

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EMPLOYEE VOLUNTARY TERM LIFE INSURANCE VOLUNTARY TERM LIFE INSURANCE BENEFIT - As shown on your Employee's Schedule of Benefits. THE TERM LIFE INSURANCE BENEFIT IS REDUCED TO THE FOLLOWING FOR YOUR EMPLOYEES: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64

SCHEDULE OF BENEFITS (continued)

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EMPLOYEE VOLUNTARY ACCIDENTAL DEATH OR BODILY INJURY BENEFIT ACCIDENTAL DEATH OR BODILY INJURY BENEFIT - As shown on Your Employee's Schedule Of Benefits. ACCIDENTAL DEATH BODILY INJURY BENEFIT IS REDUCED TO THE FOLLOWING FOR YOUR EMPLOYEES: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64


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DEPENDENT CHILD VOLUNTARY TERM LIFE INSURANCE BENEFIT DEPENDENT CHILD VOLUNTARY - BIRTH THROUGH 14 DAYS ............................................... $0 DEPENDENT CHILD VOLUNTARY - 15 DAYS UP TO 6 MONTHS ...........................................$500 DEPENDENT CHILD VOLUNTARY - FROM AGE 6 MONTHS TO ATTAINMENT OF LIMITING AGE................................................................................................................................................$5,000


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DEPENDENT SPOUSE VOLUNTARY TERM LIFE INSURANCE BENEFIT DEPENDENT SPOUSE VOLUNTARY TERM LIFE INSURANCE BENEFIT - As shown on the Schedule Of Benefits in Your Employee's Certificate. THE DEPENDENT SPOUSE TERM LIFE INSURANCE BENEFIT IS REDUCED TO THE FOLLOWING: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64


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DEPENDENT SPOUSE VOLUNTARY ACCIDENTAL DEATH OR BODILY INJURY BENEFIT ACCIDENTAL DEATH OR BODILY INJURY BENEFIT - As shown on the Schedule Of Benefits in Your Employee's Certificate. THE ACCIDENTAL DEATH OR BODILY INJURY BENEFIT IS REDUCED TO THE FOLLOWING: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64

DEFINITIONS

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The following are definitions of terms as they are used in this Certificate. Defined terms are printed in bold face type wherever found in this Certificate.

A

Active Status means the Employee is performing all of his or her customary duties whether performed at the Employer's business establishment or another location of business when required to travel on the job: • On a regular, full-time basis; • For the number of hours per week shown on the Employer Group Application; and • For 48 weeks a year. Each day of a regular paid vacation and any regular non-working holiday is deemed Active Status if the Employee is not Totally Disabled on his or her effective date of coverage. The Employee is in an Active Status if he or she was in Active Status on his or her last regular working day prior to the vacation or holiday. For Short Term Disability, an Employee who is not actively at work due to a labor dispute, including but not limited to, strike, work slowdown, or lockout is not considered to be in Active Status.

B Bodily Injury means injury due directly to an accident, independent of all other causes. Muscle strain due to athletic or physical activity is considered a Sickness.

C Confinement means being a resident patient in a Hospital or Qualified Treatment Facility for at least 15 consecutive hours. Confinement does not mean detainment in Observation Status. Successive Confinements are considered to be one Confinement if: • Due to the same Bodily Injury or Sickness; and • Separated by fewer than 30 consecutive days when You are not confined. Cosmetic Surgery means Surgery performed to reshape normal structures of the body in order to improve Your appearance and self-esteem. Covered Person means the Employee and/or the Employee's covered Dependents.

DEFINITIONS (continued)

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D Dependent means a covered Employee's: 1. Legally recognized spouse; or 2. Natural blood related child, step-child, legally adopted child, or child placed with the Employee

for the purpose of adoption whose age is less than the limiting age. 3. A child, subject to legal guardianship, grandchild or other blood relative whose age is less then

the limiting age and who depends on the Policyholder for more than fifty percent (50%) of the individual’s total support.

The limiting age for each Dependent child is: 1. The child's 26th birthday; or 2. The child's 26th birthday if the child is a regular full-time student at an accredited secondary

school, college or university. A Dependent continues to be eligible for coverage for up to four months after the close of a school term only if enrolled as a full-time student for the next school term.

A covered Dependent child who reaches the limiting age while insured under this policy remains eligible for benefits if: 1. Mentally or physically disabled; 2. Incapable of self-sustaining employment; 3. Dependent on the covered Employee for at least fifty percent (50%) of support and maintenance;

and 4. Unmarried. You need to provide Us with satisfactory proof that the above conditions continuously exist after the Dependent reaches the limiting age. We may not request proof more often than annually after two years from the date the first proof was furnished. If We do not receive satisfactory proof, the child’s coverage ends on the date proof is due.

E

Employee means a person who is permanently employed, in an Active Status at the Employer's place of business, and paid a salary or a wage by the Employer that meets the minimum wage requirements of Your state or federal minimum wage law. Employer means the Policyholder of this Group Insurance Plan, or any subsidiary described in the Employer Group Application.


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H Hospital means an institution which: • Maintains permanent full-time facilities for bed care of resident patients; • Has a physician or surgeon in regular attendance; • Provides continuous 24-hour-a-day nursing services; • Is primarily engaged in providing diagnostic and therapeutic facilities for medical or surgical care of

sick or injured persons; • Is legally operated in the jurisdiction where located; and • Has surgical facilities on its premises or has a contractual agreement for surgical services with an

institution having a valid license to provide such surgical services; or • Is a lawfully operated Qualified Treatment Facility certified by the First Church of Scientist,

Boston, Massachusetts. Hospital does NOT include an institution which is principally a rest home, nursing home, convalescent home or home for the aged. Hospital does NOT include a place principally for the treatment of alcohol or chemical dependency or Mental Disorders.

M Material And Substantial Duties are the duties that: Are normally required for the performance of the occupation; and Cannot be reasonably omitted or changed.


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You will no longer be considered Totally Disabled or Partially Disabled under this Plan when You are able to increase Your current earnings by increasing the number of hours You work or the number of duties You perform in Your regular occupation but You do not do so.

P Policyholder means the Employer who is the Legal Entity named as the Policyholder on the face page of the Policy. Pre-Existing Condition means a physical or mental condition for which You have received medical attention (medical attention means care, advice, examination, treatment, services, medication, procedures, tests, consultation, referral or diagnosis) prior to: • The effective date of Your Voluntary Term Life and/or Short Term Disability coverage under the

Policy; or • The effective date of the increased benefit for any benefits added to Your existing Voluntary Term

Life and/or Short Term Disability coverage. A diagnosis is not required for a physical or mental condition to be a Pre-Existing Condition. For the purposes of this definition, pregnancy is considered a physical condition. Pre-Existing Condition limitations applied to benefits under the Policy are described on the Schedule of Benefits.

Q Qualified Practitioner means a practitioner, professionally licensed by the appropriate state agency to diagnose or treat a Bodily Injury or Sickness, and who provides services within the scope of that license. A Qualified Practitioner does not include a practitioner who resides in Your home or is Your Family Member. Qualified Treatment Facility means only a facility, institution, or clinic duly licensed by the appropriate state agency, and is primarily established and operating within the scope of its license.

S Sickness means a disturbance in function or structure of Your body which causes physical signs or symptoms which, if left untreated, will result in a deterioration of the health state of the structure or system(s) of Your body. Surgery means excision or incision of the skin or mucosal tissues or insertion for exploratory purposes into a natural body opening. This includes insertion of instruments into any body opening, natural or otherwise, done for diagnostic or other therapeutic purposes.


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T Total Disability or Totally Disabled means, for the Employee or Employee's employed covered Dependent spouse, that during the first twelve months of disability that person is at all times prevented by Bodily Injury or Sickness from performing each and every Material And Substantial Duty of his or her respective job or occupation. After the first twelve months, Total Disability or Totally Disabled means that person is at all times prevented by Bodily Injury or Sickness from engaging in any job or occupation for wage or profit for which he or she is reasonably qualified by education, training or experience. For any Covered Dependent who is not employed, Total Disability means a disability preventing that person from performing the usual and customary activities of a person in good health and of the same age and gender. A Totally Disabled person also may not engage in ANY job or occupation for wage or profit.

W We, Us, and Our means the Insurance Company as shown on the cover page of this Certificate.

Y You and Your means any Covered Person.

ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE

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EMPLOYEE COVERAGE EMPLOYEE ELIGIBILITY DATE The Employee is eligible for coverage on the date: • Eligibility requirements stated in the Employer Group Application are satisfied; and • The Employee is in an Active Status. EMPLOYEE ENROLLMENT The Employee must enroll on forms furnished and accepted by Us. Depending on the total number of Employees covered by the Employer's plan, We may require any Employee to provide evidence of insurability and any applicable evidence of health status whenever an enrollment form is submitted. If You enroll more than 31 days after Your eligibility date, You are a late applicant and must provide Us with evidence of insurability and any applicable evidence of health status. This form is available from the Employer or Us. We have the right to accept or decline coverage. If accepted, You will be covered on the date We specify. EMPLOYEE EFFECTIVE DATE The Employee's Effective Date Provision is stated in the Employer Group Application. It may be the date immediately following, or the first of the month following, completion of the probationary period (waiting period), or the date approved by Us. EMPLOYEE DELAYED EFFECTIVE DATE If the Employee is not in Active Status on the effective date shown on the Schedule of Benefits, coverage will be effective the day after the Employee returns to Active Status. The Employer must notify Us in writing of the Employee's return to Active Status. EMPLOYEE BENEFIT CHANGES Additional or increased insurance will become effective on the approved date of change if the Employee is in Active Status on that date. Otherwise, the approved change will be effective on the day after the Employee returns to Active Status. We may require any Employee to provide evidence of insurability and any applicable evidence of health status whenever a benefit change is requested. A decrease in insurance will be effective immediately on the approved date of change.

ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE (continued)

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DEPENDENT COVERAGE DEPENDENT ELIGIBILITY DATE Each Dependent is eligible for coverage on: • The date the Employee is eligible for coverage, if he or she has Dependents who may be covered on

that date; • The date of the Employee's marriage for any Dependents (spouse or child) acquired on that date; • The date of birth of the Employee's natural-born child; or • The date the child is legally adopted or placed in the Employee's home for the purpose of adoption

by the Employee. The Employee may cover his or her Dependents ONLY if the Employee is also covered. A Dependent child who becomes eligible for other group coverage through any employment is no longer eligible for group coverage under the Policy. If a Dependent child becomes an Employee of the participating Employer, he or she is no longer eligible as a Dependent and must make application as an eligible Employee. DEPENDENT ENROLLMENT Check with the Employer immediately on how to enroll for Dependent Coverage. Late enrollment may result in denial of Dependent Coverage by Us. The Employee must enroll for Dependent Coverage and enroll additional Dependents on forms furnished and accepted by Us. No Dependent will become a Covered Person until We approve the Dependent for coverage. Depending on the total number of Employees covered by the Employer's plan, We may require any Dependent to provide evidence of insurability and any applicable evidence of health status whenever an enrollment form is submitted. If You enroll more than 31 days after Your eligibility date, You are a late applicant and must provide Us evidence of insurability and any applicable evidence of health status. This form is available from the Employer or Us. We have the right to accept or decline coverage. If accepted, You will be covered on the date We specify. NEWBORN DEPENDENT ENROLLMENT Employees who already have full Dependent (spouse and children) coverage in force PRIOR to the newborn's date of birth are not required to complete an enrollment form for the newborn child. All other Employees who are changing their current coverage must complete an enrollment form for the newborn Dependent. This form is available from Your Employer or from Us.


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DEPENDENT EFFECTIVE DATE Each Dependent's effective date of coverage is determined as follows, subject to the Dependent Delayed Effective Date provision: • If We receive the enrollment form ON, PRIOR TO or WITHIN 31 days of the Dependent's

eligibility date, that Dependent is covered on the date he or she is eligible; • If We receive the enrollment form MORE THAN 31 days after the Dependent's eligibility date, We

require evidence of insurability and any applicable evidence of health status. We have the right to accept or decline coverage for the Dependent based upon the evidence of insurability and any applicable evidence of health status. If accepted, the effective date of coverage will be the date We specify.

However, NO Dependent's effective date will be prior to the Employee's effective date of coverage. Refer to Your Schedule of Benefits for benefits available. NEWBORN DEPENDENT EFFECTIVE DATE A newborn Dependent's effective date is determined as follows: • If We receive the enrollment form ON, PRIOR TO or WITHIN 31 days of the newborn's date of

birth, Dependent Coverage is effective on the newborn's date of birth. Pre-Existing Condition limitations described in this Certificate and on the Schedule of Benefits DO NOT apply to that newborn child.

• If We receive the enrollment form MORE THAN 31 days after the newborn's date of birth, We

require evidence of insurability and any applicable evidence of health status. We have the right to accept or decline coverage for the newborn based upon the evidence of insurability and any applicable evidence of health status. If accepted, the newborn will be covered on the date We specify. Pre-Existing Condition limitations WILL apply to that newborn child.

DEPENDENT DELAYED EFFECTIVE DATE If the Dependent: • Is confined in a Hospital or Qualified Treatment Facility; or • Is receiving Home Health Care or Hospice benefits, the Dependent's effective date of coverage will be delayed. The Dependent's coverage will be effective on the day after: • Discharge from Confinement, if the discharge from Confinement is certified by a Qualified

Practitioner; or • A Qualified Practitioner certifies that Home Health Care is no longer required.


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If Dependent coverage is in force or applied for within 31 days of the newborn child's date of birth, the Dependent Delayed Effective Date provision will not apply to the newborn child on its date of birth. DEPENDENT BENEFIT CHANGES Additional or increased insurance will become effective on the approved date of change, subject to the Dependent Delayed Effective Date provision. We may require any Dependent to provide evidence of insurability and any applicable evidence of health status whenever a benefit change is requested. A decrease in insurance will be effective immediately on the approved date of change.

TERMINATION OF COVERAGE

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Termination of Coverage may be immediate or at the end of the period which was selected by Your Employer on the Employer Group Application. Insurance terminates on the earliest of the following: • The date the Group Policy terminates; • The end of the period for which required premium was due Us and not received by Us; • For an Employee, the date he or she terminates employment with the Employer; • For an Employee, the date he or she no longer qualifies as an Employee; • The date You fail to be in an eligible class of persons as provided in the Insurance Classifications as

stated in the Employer Group Application; • The date You enter full-time military, naval or air service except that termination will not occur if

You are in temporary active duty as a reservist for military training that lasts 30 days or less; • The date the Employee retires, except if the Employer Group Application provides coverage for a

retiree class of Employees and the retiree is in an eligible class of retirees, selected by the Employer, and We are notified by the Employer;

• The date the Employee requests termination of insurance to be effective for the Employee or

Dependents; • For a Dependent, the date the Employee's insurance terminates; • For a Dependent, the date he or she no longer qualifies as a Dependent; or • For any benefit, the date the benefit is deleted from the Policy. YOU AND THE EMPLOYER ARE RESPONSIBLE TO ADVISE US OF ANY CHANGES IN ELIGIBILITY INCLUDING THE LACK OF ELIGIBILITY OF ANY COVERED PERSON. COVERAGE WILL NOT CONTINUE BEYOND THE LAST DATE OF ELIGIBILITY REGARDLESS OF THE LACK OF NOTICE TO US. SPECIAL PROVISIONS FOR NOT BEING IN ACTIVE STATUS If the Employer continues to pay required premiums and continues coverage under the Policy, Your coverage, other than Short Term Disability benefits,if any, will remain in force for: • No longer than three consecutive months if the Employee is:

- Temporarily laid-off; - In part-time status; or - On an Employer approved leave of absence.

TERMINATION OF COVERAGE (continued)

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• No longer than twelve consecutive months if the Employee is Totally Disabled. If the Employee becomes Totally Disabled and wishes to apply for Waiver of Premium, We must receive premium for Employee Term Life Insurance Coverage for the six consecutive month period while the Employee is covered under the Special Provisions for Not Being in Active Status. All premium must be submitted to Us through the Employer. YOUR OPTIONS Employee Voluntary Term Life Coverage: If this coverage terminates, the Employee may exercise the rights under the Portability of Voluntary Term Life Benefit described in this Certificate, if applicable, or the Life Conversion Privilege described in this Certificate. If the Employee utilizes the Conversion Privilege, he or she thereby waives the right to Port Voluntary Term Life Coverage. If the Employee utilizes any applicable Port Privilege, he or she will have an option to Convert all or part of the coverage if the Port coverage terminates. If the Employee returns to an Active Status, he or she will be considered a new Employee and must re-enroll for Employee Coverage.

EMPLOYEE TERM LIFE INSURANCE BENEFITS

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BENEFIT The amount of the Employee Term Life Insurance benefit is shown on the Schedule of Benefits. Subject to the terms below, a payment in this amount will be made to the beneficiary named by the Employee. Payment is made when We receive proof the Employee's death occurred while insured for this benefit. The Employee Group Term Life Insurance has no cash surrender or loan values. REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if any, are shown on the Schedule of Benefits. If the Employee's death occurs on or after a reduction age, the amount of payment will be reduced by the corresponding reduction percentage shown. A reduction in benefits due to age is effective on the first day of the calendar month following the date the Employee attains that age. BENEFICIARY The Employee may name any beneficiary he or she chooses. The Employee may also change a named beneficiary at any time by notifying Us in writing. The change will be effective on the date the Employee signs the form. If We make a payment before receiving the change form, We are released from further liability to the extent of the payment. If a payment is to be made to two or more beneficiaries, but the Employee has not specified the portions payable to each, the payment will be shared equally. If the Employee has not named a beneficiary, or if the beneficiary he or she named is not alive at the Employee's death, the payment will be made, at Our option, to any one or more of the following: • Your spouse; • Your children; • Your parents; • Your brothers and sisters; or • Your estate. We will rely upon an affidavit to determine benefit payment, unless We receive written notice of a valid claim before payment is made. Payment pursuant to the affidavit will release Us from further liability. Any payment made by Us in good faith will fully discharge Us to the extent of such payment. Any amount payable to a minor will be paid to the minor's legal guardian.

EMPLOYEE TERM LIFE INSURANCE BENEFITS (continued)

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NOTICE OF DEATH No payment will be made unless We receive written proof of Your death. In order to receive benefits, written notice of death must be furnished to Us within 12 months after the date of death. If a death claim is filed more than 12 months after the date of death, We must have proof that it was not possible for the claim to be filed within 12 months. If a death claim is filed while the Waiver of Premium is in effect, proof of continuous Total Disability must accompany the death claim. LIMITED BENEFITS FOR SELF-INDUCED SICKNESS, SUICIDE OR SELF-INFLICTED BODILY INJURY In the event of death caused by self-induced Sickness, suicide, or intentional self-inflicted Bodily Injury, whether sane or insane, within the first year of Your effective date under this Certificate, benefits for Employee Voluntary Term Life Insurance will be limited to the premium paid for the Employee Voluntary Term Life Insurance. EMPLOYEE LIFE INSURANCE CONVERSION PRIVILEGE The Employee is entitled to apply for a Conversion Policy of Life Insurance if any portion of his or her Term Life Insurance Benefit terminates due to: • Termination of employment or membership in a class eligible for Term Life Insurance. The amount

the Employee is entitled to apply for is the amount of Term Life Insurance that is terminating, LESS the amount of Term Life Insurance for which he or she becomes eligible under any group coverage within 31 days after such termination; or

• Reduction for Age. The amount the Employee is entitled to apply for is the amount of insurance lost

due to the reduction, but not more than $10,000. If the Employee's Term Life Insurance benefit terminates because this coverage terminates, or is amended so as to terminate the eligible class to which the Employee belongs, and his or her Employee Term Life Insurance has been in effect under the Policy for at least three years, the amount the Employee is entitled to apply for is the lesser of: • The amount of Employee Term Life Insurance that is terminating, LESS the amount of any Life

Insurance for which he or she becomes eligible under any group coverage within 31 days after such termination; or

• $10,000.


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CONVERSION POLICY The Conversion Policy is issued without evidence of insurability. The Employee must apply for and pay the first premium within 31 days of the termination of the Employee's coverage under the Group Plan. The Conversion Policy will be effective on the 32nd day following such termination. The Conversion Policy will not include any Short Term Disability or Accidental Death or Bodily Injury benefits. It will be issued on any one of the Policy forms, except term insurance, then being issued by Us to individuals of the same age. Premiums for the Conversion Policy will be based on Our current rate for the form, amount of insurance and the Employee's age on the date of issue of the Conversion Policy. DEATH DURING CONVERSION PERIOD If the Employee dies during the 31 day period that he or she could have applied for a Conversion Policy, the amount of Life Insurance the Employee could have converted will be paid as the death benefit, even if the Employee had not applied for the Conversion Policy. NOTICE OF RIGHT TO CONVERT If the Employee has not received notice of his or her right to convert to an individual policy within 15 days before the end of the 31 day conversion period, the Employee will have an additional 15 days from the date the Employee is notified in which to convert; provided, however, that the life insurance coverage under the Policy will not extend beyond the 31st day after termination of the Employee's employment, nor will the Employee's right to convert be extended more than 60 days beyond the Employee's initial 31 day conversion period. THE FOLLOWING EXCLUSIONS ARE APPLICABLE TO VOLUNTARY TERM LIFE BENEFITS IF SHOWN ON YOUR SCHEDULE OF BENEFITS. LIMITATIONS Voluntary Term Life Benefits do not cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane

or insane within the first year of Your effective date. Benefits will be limited to the premium paid for this Employee Voluntary Term Life Insurance;

• The voluntary taking of any sedative, drug, alcohol, poison or inhalation of any gas unless taken or

inhaled as prescribed or administered by a Qualified Practitioner within the first year of Your effective date. Benefits will be limited to the premium paid for this Employee Voluntary Term Life Insurance;

• Travel or flight in a device of any type for aerial navigation, except as a fare-paying passenger of a

licensed passenger airline; • Commission or attempt to commit a civil or criminal battery or felony;


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• Service in any armed forces, except if You are in temporary active duty as a reservist for military

training that lasts 30 days or less; • Bodily Injury or Sickness contributed to or caused by;

- War or any act of war, whether declared or not; or - Any act of armed conflict, or any conflict involving armed forces of any authority; or

• Participation in a riot, rebellion or insurrection. Participation means taking an active part in common with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law.

WAIVER OF PREMIUM

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If the Employee becomes Totally Disabled while insured for this Employee Term Life Insurance Benefit, We will continue the Employee's Term Life Insurance Benefit during his or her Total Disability without the requirement of premium payment subject to the Waiver of Premium provision. In order for Us to approve Waiver of Premium, the Employee must: • Become Totally Disabled before age 60; • Remain Totally Disabled throughout the 180 consecutive day Elimination Period;

Elimination Period means a period of continuous disability which must be satisfied before You are eligible to have Your life premium waived by Us.

• Request an application for Waiver of Premium and submit such application with proof of Total Disability, acceptable to Us, no later than 12 consecutive months after the Employee first became Totally Disabled.

Premium payment must continue until We approve the application for Waiver of Premium. Failure to do so will result in forfeiture of Your rights to Wavier of Premium. The Wavier of Premium benefit begins at the end of the Elimination Period. If the Employee dies prior to submitting the initial proof of Total Disability as required, proof that the Total Disability continued until the date of the Employee's death must be given to Us no later than 12 months after the Employee's death. We will not approve an application for Waiver of Premium if the Employee becomes Totally Disabled after the Employer terminates coverage under the Policy. EFFECT OF WAIVER OF PREMIUM When We approve Waiver of Premium, no premium payment will be required for the Employee's Term Life Insurance benefit during his or her Total Disability. Proof of the Total Disability must be received by Us within one year from the date the Total Disability began. The Employee is required to submit proof of continued Total Disability to Us three months before each anniversary date of the disability. We have the right to have the Employee examined for the Total Disability at any reasonable time during the first two years he or she is Totally Disabled. After that, We may have the Employee examined only once a year. AMOUNT CONTINUED The amount of the Employee Term Life Insurance benefit which will be continued under this Waiver of Premium is the amount that was in effect for the Employee on the date the Total Disability began. This amount will be reduced by the same amount, on the same dates, and for the same reasons that it would have been reduced if the Employee had not become Totally Disabled.

WAIVER OF PREMIUM (continued)

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TERMINATION OF WAIVER OF PREMIUM The Waiver of Premium terminates on the earliest of: • The date the Employee fails or refuses to furnish proof of Total Disability as required; • The date the Employee fails or refuses to be examined as required; • The date the Employee is no longer Totally Disabled; or • The Employee's 65th birthday. If the Waiver of Premium benefit terminates and the Employee returns to an Active Status, he or she will be insured for the Employee Term Life Insurance benefit for which he or she is then eligible. Premium payment will be required for the Employee Term Life Insurance benefit. If this Waiver of Premium terminates because the Employee is no longer Totally Disabled or attains age 65, and does not return to an Active Status, he or she may apply for a Conversion Policy of Life Insurance according to the Conversion Privilege provision in this Certificate. Termination of the Employer's participation under the Policy WILL NOT terminate the Employee's Waiver of Premium. If the Waiver of Premium terminates after the Employer's participation under the Policy terminates, and if the Employee Term Life Insurance Benefit has been in force for at least three years, the Employee may apply for a Conversion Policy. The amount of any Conversion Policy is limited to the lesser of: • The amount of Employee Term Life Insurance that is terminating LESS the amount of any Life

Insurance for which the Employee becomes eligible under any group coverage within 31 days after such termination; or

• $10,000.

ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR COVERED EMPLOYEES

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Subject to the terms below, a benefit is payable for loss due to the Employee's Accidental Death or Accidental Bodily Injury if shown on the Schedule of Benefits. The loss must: (a) occur within 180 days after the accident which caused the loss; and (b) be due to an accident which occurs while the Employee is insured under the Benefit. If the Employee suffers multiple losses in the same accident, Our liability will be limited to payment for the one type of loss which provides the greatest benefit. The amount of benefit payable for each type of loss is: LOSS OF LIFE OR BENEFIT OTHER THAN BENEFIT FOR DISMEMBERMENT BENEFIT A COMMON CARRIER COMMON CARRIER ACCIDENT ACCIDENT Loss of Life Full Amount 2 Times Full Amount Loss of both hands Full Amount 2 Times Full Amount Loss of both feet Full Amount 2 Times Full Amount Loss of sight of both eyes Full Amount 2 Times Full Amount Loss of one hand and one foot Full Amount 2 Times Full Amount Loss of one hand or one foot and sight of one eye Full Amount 2 Times Full Amount Loss of one hand One-Half of the Full Amount Full Amount Loss of one foot One-Half of the Full Amount Full Amount Loss of sight of one eye One-Half of the Full Amount Full Amount Loss of thumb and index finger One-Fourth of the One-Half of the of the same hand Full Amount Full Amount

ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR COVERED EMPLOYEES (continued)

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PARALYSIS BENEFIT The paralysis must be determined by a Qualified Practitioner to be permanent, complete and irreversible. BENEFIT OTHER THAN BENEFIT FOR A COMMON CARRIER COMMON CARRIER ACCIDENT ACCIDENT Quadriplegia Full Amount 2 Times Full Amount Paraplegia One-Half of the Full Amount Full Amount Hemiplegia One-Half of the Full Amount Full Amount REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if applicable, are also shown on the Schedule of Benefits. If the Employee's loss occurs on or after a reduction age is effective, the full amount shown on the Schedule of Benefits will be reduced by the corresponding reduction percentage shown. This means that if the accident occurs before the effective date of the reduction age, but the Employee's loss occurs on or after the effective date of the reduction age, We will pay the benefit based on the reduced amount. A reduction age is effective on the first day of a calendar month following the date the Employee attains that age. TO WHOM PAYABLE Benefits for Accidental Dismemberment, or Paralysis are payable to the Employee. Benefits for Accidental Death are payable in accordance with the Employee Term Life Insurance Benefits provision - Beneficiary section. DEFINITIONS • ACCIDENTAL DEATH Accidental Death means loss of life which results directly from:

- Bodily Injury; - Infection caused by Bodily Injury, or infection resulting from accidental ingestion of

contaminated substances; or - Accidental drowning.


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• ACCIDENTAL DISMEMBERMENT Accidental Dismemberment means complete, permanent and irretrievable loss, resulting directly from Bodily Injury of:

- A hand or foot by severance at or above the wrist or ankle joint; or - The sight of an eye.

• COMMON CARRIER ACCIDENT Common Carrier Accident means a covered accidental Bodily Injury that is sustained while riding as a fare-paying passenger (not a pilot, operator or crew member) in or on, boarding or getting off from a common carrier. • COMMON CARRIER Common Carrier means any land, air or water vehicle operated under a valid license to transport passengers for hire. • QUADRIPLEGIA Quadriplegia means total paralysis of all four limbs. • PARAPLEGIA Paraplegia means total paralysis of both lower limbs. • HEMIPLEGIA Hemiplegia means total paralysis of one arm and one leg on the same side of the body. REPATRIATION BENEFIT We will pay a Repatriation Benefit if: 1. The Employee dies as a result of a accidental death at least 150 miles from his or her principal place

of residence; and 2. Expense is incurred for preparing the Employee's body and transporting the Employee's body to a

mortuary. This benefit will be in addition to all other benefits payable under this Certificate. This benefit will equal the expenses incurred for preparing and transporting the Employee's body to a mortuary, subject to the maximum of $5,000. This benefit will be paid the date both proof of accidental loss of life and proof of expense incurred for preparing and transporting the body is received.


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PROOF FOR REPATRIATION BENEFIT For this benefit to be payable, proof of payment for any expense incurred for repatriation must be provided to Us. TO WHOM PAYABLE FOR REPATRIATION BENEFIT Benefits for repatriation will be paid in accordance with the Beneficiary Section of this Certificate. Benefits will not be payable for any loss excluded under the Accidental Death or Bodily Injury for covered Employees Limitations section. EDUCATION BENEFIT We will pay an Education Benefit for each of the Employee's eligible Dependent children if the Employee: • Is injured in a covered accident while insured under this Certificate; • Dies as a direct result of these injuries within 365 days after the accident; and • Is survived by one or more Dependent children who are eligible for the benefit. To be eligible for the Education Benefit, a Dependent Child: • Must be Dependent on the Employee for principal support; • Must be enrolled as a full-time student on the date of the Employee's death or within 365 days after

the date of death; and • Must incur expenses after the date of the Employee's death for tuition, fees, books, room and board,

approved or certified by that school, paid by the student or payable directly to that school. This benefit will be paid in addition to all other benefits payable under this Certificate. The benefit will equal the actual expense incurred after the date of the Employee's death up to 5% of the Employee's death benefit, subject to a maximum of $5,000 for each eligible Dependent child per year, for up to four (4) consecutive years or until age 25 if all eligibility requirements are met for each payment. This benefit will be paid to the Dependent child if the child has reached the age of majority. Otherwise, benefits will be paid to the child's legal guardian. The first payment will be paid, the date both proof of accidental loss of life and proof of Educational expenses and that the Dependent child meets the above requirements is received. Subsequent payments will be made when We receive: • Verification that the eligible Dependent child continues to be a full-time student and meets the

requirements of this benefit during each additional semester/year; and • Proof of payment for the expenses incurred.


GN-70051-07 EM ADD 5/2005 30

"Full-time student" means a Dependent child who: • Is attending a licensed or accredited college, university or vocational school beyond the 12th grade; • Is considered a full-time student based upon that school's standards; and • Incurs expenses for tuition, fees, books, room and board, or other costs approved or certified by that

school, paid by the student or payable directly to that school. SPOUSE TRAINING BENEFIT A Spouse Training Benefit will be paid to the Employee's lawful recognize spouse, if the Employee: • Dies as a direct result of an Accidental Death; and • Is survived by a spouse who is eligible for the benefit. To be eligible for the Spouse Training Benefit, the Employee's spouse: • Must be the lawfully recognized spouse of the Employee on the date of the accident; • Must be enrolled as a student on the date of the Employee's death or within 365 days after that date

of the Employee's death in an accredited school; and • Must incur expenses after the date of the Employee's death for tuition, fees, books, room and board

or other costs approved or certified by the school, paid by the student or payable directly to that school.

This benefit will be paid in addition to all other benefits payable under this Certificate. The benefit will equal the actual expense incurred after the date of the Employee's death up to 5% of the Employee's benefit, subject to a maximum of $5,000. This benefit will be paid for one year after the Employee's death. Payment will be made the date both proof of accidental loss of life and proof of expense incurred for Spousal Training and the spouse meets the above requirement is received. EXCLUSIONS FOR SPOUSE TRAINING BENEFIT Benefits will not be payable for any loss excluded under the Accidental Death or Bodily Injury Benefit for Covered Employees Limitation section. CHILD CARE BENEFIT A Child Care Benefit will be paid for each of the Employee's eligible Dependent children if the Employee: • Is injured in a covered accident while insured under this Certificate; • Dies as a direct result of these injuries within 365 days after the accident; and • Is survived by one or more Dependent children who are eligible for the benefit.


GN-70051-07 EM ADD 5/2005 31

To be eligible for the Child Care Benefit, a Dependent child must: • Meet all the qualifications of a Dependent as determined by the Internal Revenue Service; • Be declared on and legally qualify as a Dependent on the Employee's Federal personal income tax

return filed for each year the benefits are request under the Child Care Benefit; • Be under age 13 on the date of the accident; and • Attends a licensed Child Care Center, once a week or on a more frequent basis, on the date of the

Employee's death or within 365 days after that date. The Child Care Benefit is paid in addition to all other Certificate benefits. The benefit will equal the actual expense incurred after the date of the Employee's death, up to 5% of the Employee's benefit, subject to a maximum of $5,000 for each eligible Dependent child per year. The benefit will be paid to the legal guardian of the eligible Dependent child the earliest of the following: • For up to four (4) consecutive years; or • Until the Dependent child's 13th birthday. The first payment will be made the date proof of accidental loss of life and proof of expenses incurred for Child Care and that the eligible Dependent child meets the above requirements is received. Subsequent payment will be made on a reimbursement basis when We receive: • Verification that the eligible Dependent child continues to attend a licensed Child Care Center on a

regular basis; and • Satisfactory proof of payment for the childcare expense incurred. DEFINITIONS • CHILD CARE CENTER Child Care Center means any facility, other than a family day care home that:

- Is licensed as a Child Care Center by the state in which it is physically located, and where the Dependent child physically attends; and

- Provides non-medical care and supervision for children in a group setting: and - Cares for children at least six (6) but less than 24 hours per day.

• EXPENSE INCURRED Expense incurred means the cost for the supervision and care of a Dependent child, excluding any fees for extra activities that are directly payable to a Child Care Center.


GN-70051-07 EM ADD 5/2005 32

EXCLUSIONS FOR CHILD CARE BENEFIT Benefits will not be paid: • When the Dependent Child's care is provided by, or at a facility operated by the child's grandparent,

parent, aunt, uncle or sibling; or • For any loss excluded under the Accidental Death or Bodily Injury for Covered Employees

Limitation section of this Certificate. COMA BENEFIT Coma means being in a state of complete mental and physical unresponsiveness in which neither arousal nor awareness is present and there is no evidence of appropriate responses to stimulation. We will pay a Coma Benefit when the Employee remains in a Coma if: • The Coma is caused by a Bodily Injury sustained while insured under this Certificate; • The Coma begins within 365 days after the date of the accident; and • The person remains in a Coma for more than 31 consecutive days. The Coma must result directly from the Bodily Injury and from no other causes. The benefit will be paid in addition to all other benefits payable under this Certificate. The Coma Benefit will equal a one time payment of 5% of the Employee's benefit, subject to a maximum of $5,000. PROOF FOR COMA BENEFIT Proof of the Coma must be provided to Us. We retain the right to investigate and to determine whether the coma exists. TO WHOM PAYABLE FOR COMA BENEFIT Upon receipt of satisfactory proof, the Coma Benefit will be paid to the Employee. EXCLUSIONS FOR COMA BENEFIT Benefits will not be paid: • When the Employee remains in a coma for less than 31 consecutive days; or • For any loss excluded under the Accidental Death or Bodily Injury for Covered Employees

Limitation section of this Certificate.


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SEAT BELT - AIRBAG - HELMET BENEFIT The Seat Belt, Airbag, Helmet Benefit is payable if You die as a direct result of Bodily Injury sustained in an automobile or motorcycle accident as a passenger or driver. In the event of an automobile accident the benefit is payable if: • A copy of the police report is submitted with the claim; • You were seated in a seat equipped with a properly functioning air bag; • You were wearing a properly fastened seat belt in the correct position; and • The correct position of the seat belt was certified by the investigating officer or indicated in the police

report. We will increase Your Accidental Death benefit by 10%, up to $10,000, but not less than $1,000 for using Your seat belt. Additionally, We will increase Your Accidental Death benefit by 5%, up to $5,000, but no less than $500 for the properly functioning airbag. In the event of a motorcycle accident the benefit is payable if: • A copy of the police report is submitted with the claim: • You were wearing a properly fitting and fastened motorcycle helmet; and • The use of properly fitted and fastened motorcycle helmet was certified by the investigating officer or

indicated in the police report. We will increase Your Accidental Death benefit by 10%, up to $10,000, but not less than $1,000 for wearing a properly fitted and fastened motorcycle helmet. If We are unable to determine whether You had been wearing a properly fastened seat belt, seated in a seat equipped with a functioning airbag, or wearing a properly fitted and fastened motorcycle helmet. We will pay a benefit of $1,000 to Your beneficiary. DEFINITIONS • AUTO Auto means a four-wheel passenger car, station wagon, sport utility vehicle, truck or van-type car. It must be licensed for use on public highways. It includes a car owned or leased by a group certificate holder. • MOTOR CYCLE Motor Cycle means a two wheel passenger motorcycle. It must be licensed for use on public highways. it includes a motorcycle owned or leased by a group certificate holder.


GN-70051-07 EM ADD 5/2005 34

LIMITATIONS Accidental Death or Bodily Injury benefits DO NOT cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane

or insane; • The voluntary taking of any sedative, drug, alcohol, poison or inhalation of any gas unless taken or

inhaled as prescribed or administered by a Qualified Practitioner; • Being intoxicated or under the influence of any unlawful substance, narcotic or hallucinogenic, unless

administered on the advice of a Qualified Practitioner; • Travel or flight in a device of any type for aerial navigation, except as a fare-paying passenger of a

licensed passenger airline; • Commission or attempt to commit a civil or criminal battery or felony; • Driving or operating a motorized vehicle while legally intoxicated or under the influence of illegal

substance. Intoxication means that blood alcohol content or the results of other means of testing blood alcohol level meet or exceeds the legal presumption of intoxication under the law of the state where the accident took place;

• Driving or operating a motorized vehicle without a valid drivers' license; • Driving or operating a motorized vehicle in excess of the legal speed limit; • Service in any armed forces, except if You are in temporary active duty as a reservist for military

training that lasts 30 days or less; • Bodily Injury or Sickness contributed to or caused by:

− War or any act of war, whether declared or not; or − Any act of armed conflict, or any conflict involving armed forces of any authority;

• Bodily or mental infirmity, or its related surgical or medical treatment or any infection unless the

direct result of Bodily Injury, or unless resulting from the accidental ingestion of a contaminated substance;

• Participation in a riot, rebellion or insurrection. Participation means taking an active part in common

with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law; or

• Participation in hazardous sports, including but not limited to: bungee jumping, motorized vehicle

racing, rock climbing, rodeo events, scuba diving, skydiving, parachuting, hang gliding, or ballooning.

ACCELERATED DEATH BENEFITS

IN-70051-07 EM ADB 35

If a covered Employee is diagnosed with a Terminal Illness, the Employee may request that an accelerated benefit be paid immediately. The amount payable is 50% to a maximum benefit of $250,000. DEFINITIONS Terminal Illness means a Sickness or Bodily Injury which is diagnosed by a Qualified Practitioner as life-threatening with a life expectancy of 24 months or less. QUALIFICATIONS FOR ACCELERATED BENEFITS Payment of this benefit does not guarantee that the Employee's full death benefit will eventually be paid. The Employee must still be insured under the Policy at the time of death for the remainder of the Term Life Insurance benefit to be paid. The Employee must be covered under this Benefit a minimum of 30 days when applying for Accelerated Death Benefit due to a Sickness. The Accelerated Death Benefit is effective for Bodily Injury upon the effective date of this Benefit. To qualify for the Accelerated Death Benefit the covered Employee must: • Provide proof of Terminal Illness acceptable to Us; • Request this benefit in writing on a form acceptable by Us; and • Provide written consent stating any beneficiary has agreed to payment of the Accelerated Death

Benefit on the Employee's behalf. BENEFITS PAYABLE Payment will be made in one lump sum to You and is payable once during Your lifetime. The amount requested must be at least $5,000. If the amount of Your Term Life Insurance is scheduled to reduce within 6 months following the date You apply for the Accelerated Death Benefit, Your benefit payable will be based on the reduced amount. Payment from this benefit may be taxable. Assistance should be sought from Your personal tax advisor. We are not responsible for any tax or other effects of an accelerated benefit payment or loss of eligibility for any State or Federal program.

ACCELERATED DEATH BENEFITS (continued)

IN-70051-07 EM ADB 36

PROOF OF TERMINAL ILLNESS Proof of Terminal Illness requires a Qualified Practitioner's written certification that the Employee has 24 months or less to live. We reserve the right to request any additional medical information We believe necessary to confirm the Employee's status. If You fail to submit proof satisfactory to Us that You have a Terminal Illness, or refuse to be examined as may be required by Us, no Accelerated Death Benefit will be payable. EXCLUSIONS • Accelerated Death Benefits are not available for a Terminal Illness which resulted from a self-

induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane or insane; or

• Accelerated Death Benefits are not payable to an Employee who is:

- Required by law to use this benefit to satisfy claims of creditors; or - Required by a government agency to use this benefit to apply for, obtain or keep a government

benefit or entitlement. EFFECT ON EMPLOYEE TERM LIFE INSURANCE BENEFIT The amount of Term Life Insurance payable to the beneficiary at the time of death will be reduced by any accelerated benefit amount paid. The remaining Term Life Insurance amount will be paid according to the terms and provisions of the Policy. Any amount You could otherwise convert will also be reduced by the accelerated benefit. FRAUD If You commit fraud and We have paid an Accelerated Death Benefit under the Policy, You will reimburse Us for any such benefit payment.

GENERAL PROVISIONS

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NOTICE OF CLAIM Written notice of claim, other than claim for loss of life, must be given within 30 days after the date of loss covered by this Policy, or as soon thereafter as is reasonably possible. Notice may be given at Our address and should include Your name and the name(s) of Your Dependent(s) and Your Group Number. Written notice of claim for loss of life must be furnished to Us within 12 months after the date of death. If a death claim is filed later, We must have proof that is was not possible for the claim to be filed within 12 months. CLAIM FORMS Upon receipt of notice of claim, We will send You the forms for filing proof of loss. If the forms are not sent to You within 15 days, You will have met the proof of loss requirement by sending Us a written statement of the nature and extent of the loss within the time limit stated in the Proof of Loss provision. PROOF OF LOSS You must give written proof of loss within 90 days after the date of loss, except for loss of life. Your claim will not be reduced or denied if it was not reasonably possible to give such proof. In any event, written notice must be given within one year after the date proof of loss is otherwise required, except if You were legally incapacitated. TIME OF PAYMENT OF CLAIMS Payments due under the Policy will be paid upon receipt of written proof of loss. CLAIM APPEAL PROCEDURE If We partially or fully deny a claim for benefits submitted by You, and You disagree or do not understand the reasons for this denial, You may appeal this decision. You have the right to: • Request a review of the denial; • Review pertinent plan documents; and • Submit in writing, any data, documents or comments which are relevant to Our review of this denial. Your appeal must be submitted in writing within 60 days of receiving written notice of denial. We will review all information and send written notification within 60 days of Your request.

GENERAL PROVISIONS (continued)

IN-70051-07 EM GP 38

INCONTESTABILITY After You are insured without interruption for two years, We cannot contest the validity of Your coverage except for: • Nonpayment of premium; • Your ineligibility under the Policy; • Any Policy provision; • Any fraudulent misrepresentation made by You; or • Any defenses We may have by law. No statement made by You can be contested unless it is in a written form signed by You. A copy of the form must be given to You or Your beneficiary. An independent incontestability period begins for each type of change in coverage or when We require a new Employee Enrollment Form. This provision only limits Our right to void Your coverage after You have been insured without interruption for two years. FRAUD If You commit fraud against Us or Your Employer commits fraud pertaining to You against Us as determined by a court of competent jurisdiction, Your coverage ends automatically, without notice. TIME LIMIT ON CERTAIN DEFENSES A claim will not be reduced or denied after two years from the effective date of the benefit because a disease or physical condition not excluded and causing the loss existed before the benefit effective date. CLERICAL ERROR, MISSTATEMENT OF AGE OR GENDER If it is determined that information about the age or gender of You or Your Dependents was omitted or misstated in error, the amount of insurance for which You are properly eligible will be in effect. An equitable premium adjustment will be made. This provision applies equally to You and to Us. DUPLICATING PROVISIONS If any charge is described as covered under two or more benefit provisions, We will pay only under the provision allowing the greater benefits. This may require Us to make a recalculation based upon both the amounts already paid and the amounts due to be paid. We have NO liability for benefits other than those the Policy provides.


IN-70051-07 EM GP 39

WORKERS' COMPENSATION NOT AFFECTED This Plan is not issued in lieu of, nor does it affect any requirement for coverage by any Workers' Compensation or Occupational Disease Act or Law. RIGHT TO REQUEST OVERPAYMENTS We reserve the right to recover any payments made by Us that were made in error. RIGHT TO COLLECT NEEDED INFORMATION You must cooperate with Us and when asked, assist Us by: • Authorizing the release of medical information including the names of all providers from whom You

received medical attention; • Obtaining medical information and/or records from any provider as requested by Us; • Providing information regarding the circumstances of Your injury or accident; • Providing information about other insurance coverage and benefits; and • Providing information We request to administer the Policy. PHYSICAL EXAMINATION AND AUTOPSY We, at Our expense, have the right to have You examined as often as We deem reasonably necessary. We may also have an autopsy performed unless prohibited by law. LEGAL ACTIONS You cannot bring an action at law or equity to recover a claim until 60 days after the date written proof of loss is made. You cannot bring such action more than three years after such proof of loss is made. ASSIGNMENT OF BENEFITS FOR LIFE COVERAGE Except for the dismemberment benefits under the Accidental Death and Bodily Injury Benefit for Covered Employees. You have the right to absolutely assign all of Your rights and interest under the Policy including, but not limited to, the following: • The right to make any contributions required to keep the insurance in force; • The privilege of converting; and • The right to name and change a beneficiary. If an Irrevocable beneficiary has been designated, Assignment of Benefit will not be allowed.


IN-70051-07 EM GP 40

No absolute assignment of rights and interest shall be binding on Us until and unless the original or certified copy of the form documenting the absolute assignment is received and acknowledge by Us at our office. We have no responsibility: • For the validity or effect of any assignment; or • To provide any assignee with notice which We may be obligated to provide to You. WORKER'S COMPENSATION If benefits are paid by Us and We determine You received Workers' Compensation for the same incident, We have the right to recover as described under the "Recovery Rights" provision. We will exercise Our right to recover against You. The Recovery Rights will be applied even though: • The Workers' Compensation benefits are in dispute or are made by means of settlement or

compromise; • NO final determination is made that Bodily Injury or Sickness was sustained in the course of or

resulted from Your employment; • The amount of Workers' Compensation due to medical or health care is not agreed upon or defined by

You or the Workers' Compensation carrier; or • The medical or health care benefits are specifically excluded from the Workers' Compensation

settlement or compromise. You hereby agree that, in consideration for the coverage provided by the Policy, You will notify Us of any Workers' Compensation claim You make, and that You agree to reimburse Us as described above. MODIFICATION OF POLICY The Policy may be modified at any time by agreement between Us and the Policyholder without the consent of any Covered Person or any beneficiary. No modification will be valid unless approved by Our President or Secretary. The approval must be endorsed on or attached to the Policy. No agent has authority to modify the Policy, or waive any of the Policy provisions, to extend the time of premium payment, or bind Us by making any promise or representation. PREMIUM CONTRIBUTIONS Your Employer must pay the required premium to Us as they become due. Your Employer may require You to contribute toward the cost of Your insurance. Failure of Your Employer to pay any required premium to Us on time will result in the termination of Your insurance.


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GRACE PERIOD A grace period of 31 days will be allowed for payment of each premium due. If premium due is not paid within the grace period, We will cancel the insurance at the end of the grace period. All due and unpaid premium, including premium for the grace period, must be paid to Us by Your Employer. RECOVERY RIGHTS RIGHT OF SUBROGATION If, after payments have been made under this Plan, You or Your covered Dependents have a right to recover damages from a responsible party, We will be subrogated to Your rights to recover. You or Your covered Dependent will do whatever is necessary to enable Us to exercise Our right and will do nothing after loss to prejudice it. If We are precluded from exercising Our Right of Subrogation, We may exercise Our Right of Reimbursement. RIGHT OF REIMBURSEMENT If benefits are paid under this Plan and You or Your covered Dependent recovers from a responsible party by settlement, judgment or otherwise, We have a right to recover from You or Your covered Dependent an amount equal to the amount We paid. ASSIGNMENT OF RECOVERY RIGHTS This Plan contains an exclusion for Sickness or Bodily Injury for which there is Short Term Disability coverage provided or payable under any premises or other similar coverage. If Your claim against the other insurer is denied or partially paid, We will process Your claim according to the terms and conditions of the Policy. If payment is made by Us on Your behalf, You agree to assign to Us any right You have against the other insurer for income benefits We pay.

SUPPLEMENTAL BENEFIT DEPENDENT TERM LIFE INSURANCE BENEFITS

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This benefit is attached to and made a part of Your Certificate. The effective date of this change is the latter of the effective date of this Certificate or the date this benefit is added to the Policy. Except as modified below, all Policy terms, conditions, and limitations apply. The amount of the Dependent Term Life Insurance Benefit is shown on the Schedule of Benefits. In no event will the Dependent Term Life Insurance Benefit exceed 50% of the amount of the Employee Life Insurance amount. BENEFITS The applicable Dependent Term Life Insurance Benefit will be paid to the beneficiary subject to the terms below: • The covered Dependent dies while coverage is in force; and • Proof of death is received that the Dependent's death occurred while insured for this benefit. Dependent Term Life Insurance has no cash surrender or loan values. REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if any, are shown on the Schedule of Benefits. If the Dependent's death occurs on or after a reduction age, the amount of payment will be reduced by the corresponding reduction percentage shown. A reduction in benefits due to age is effective on the first day of the calendar month following the date the Dependent attains that age. BENEFICIARY The Employee will be paid the applicable amount of Dependent Term Life Insurance shown on the Schedule of Benefits in the event of death of one of his or her covered Dependents. If the Employee does not survive the Dependent, the applicable Dependent Term Life Insurance amount will be payable, at Our option, to one or more of the following; • Your parents; • Your children; • Your brothers and sisters; or • Your estate. We will rely upon an affidavit to determine benefit payment, unless We receive written notice of valid claim before payment is made. Payment pursuant to the affidavit will release Us from further liability. Any payment made by Us in good faith will fully discharge Us to the extent of such payment. Any amount payable to a minor will be paid to the minor’s legal guardian.

SUPPLEMENTAL BENEFIT DEPENDENT TERM LIFE INSURANCE BENEFITS (continued)

IN-70051-07 EM DL 3/2004 43

NOTICE OF DEATH No payment will be made unless We receive written proof of Your death. In order to receive benefits, written notice of death must be furnished to Us within 12 months after the date of death. If a death claim is filed more than 12 months after the date of death, We must have proof that it was not possible for the claim to be filed within 12 months. LIMITED BENEFITS FOR SELF-INDUCED SICKNESS, SUICIDE OR SELF-INFLICTED BODILY INJURY In the event of death caused by self-induced Sickness, suicide, or intentional self-inflicted Bodily Injury, whether sane or insane, within the first year of Your effective date under this Certificate, benefits for Voluntary Dependent Term Life Insurance will be limited to the premium paid for the Voluntary Dependent Term Life Insurance. DEPENDENT LIFE INSURANCE CONVERSION PRIVILEGE A covered Dependent may apply for a Conversion Policy of Life Insurance if the Dependent's Term Life Insurance benefit terminates because: • The Employee's employment terminates; • The Employee dies or transfers to a class of Employees not eligible for coverage under the Policy; or • The Dependent ceases to qualify as a Dependent. The amount the Dependent is entitled to apply for is the amount of Term Life Insurance in force for the Dependent under this Plan at the time coverage terminates. A covered Dependent may also apply for a Conversion Policy of Life Insurance if the Dependent Term Life Insurance benefit terminates due to a Policy amendment removing the Dependent Life Insurance Benefit or termination of the Policy, and the Dependent's Term Life Insurance has been in effect under this Plan for at least three years. The amount the covered Dependent is entitled to apply for is the lesser of: • The amount of Dependent Term Life Insurance that is terminating LESS the amount of any Life

Insurance for which that Dependent becomes eligible within 31 days after such termination; or • $10,000.


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CONVERSION POLICY The Life Conversion Policy is issued without evidence of insurability. The Employee, on behalf of the covered Dependent, must apply for and pay the first premium within 31 days of the termination of the Dependent's coverage under the group Plan. The Conversion Policy will be effective on the 32nd day following such termination. The Conversion Policy will not include any Disability or Accidental Death or Bodily Injury benefits. It will be issued on any one of the policy forms, except term insurance, then being issued by Us to individuals of the same age. Premiums for the Conversion Policy will be based on Our current rate for the Policy form, amount of insurance and the covered Dependent's age on the date of issue of the Conversion Policy. DEATH DURING CONVERSION PERIOD If the covered Dependent dies during the 31 day period that he or she could have applied for a Conversion Policy, the amount of Life Insurance he or she could have converted will be paid as the death benefit, even if the Dependent had not applied for the Conversion Policy. NOTICE OF RIGHT TO CONVERT If the covered Dependent has not received notice of his or her right to convert to an individual policy within 15 days before the end of the 31 day conversion period, the covered Dependent will have an additional 15 days from the date the covered Dependent is notified in which to convert; provided, however, that the life insurance coverage under the Policy will not extend beyond the 31st day after termination of the covered Dependent's coverage, nor will the covered Dependent's right to convert be extended more than 60 days beyond the covered Dependent's initial 31 day conversion period. THE FOLLOWING EXCLUSIONS ARE APPLICABLE TO VOLUNTARY TERM LIFE BENEFITS IF SHOWN ON YOUR SCHEDULE OF BENEFITS. LIMITATIONS Voluntary Term Life Benefits do not cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane

or insane within the first year of Your effective date. Benefits will be limited to the premium paid for this Voluntary Dependent Term Life Insurance;


inhaled as prescribed or administered by a Qualified Practitioner within the first year of Your effective date. Benefits will be limited to the premium paid for this Voluntary Dependent Term Life Insurance;


licensed passenger airline;


IN-70051-07 EM DL 3/2004 45

• Commission or attempt to commit a civil or criminal battery or felony; • Service in any armed forces, except if You are in temporary active duty as a reservist for military


- War or any act of war, whether declared or not; or - Any act of armed conflict, or any conflict involving armed forces of any authority; or

• Participation in a riot, rebellion or insurrection. Participation means taking an active part in common with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law.


SUPPLEMENTAL BENEFIT ACCIDENTAL DEATH OR BODILY INJURY BENEFIT FOR

COVERED DEPENDENT SPOUSE

GN-70051-07 EM ADDS 5/2005 46

This benefit is attached to and made a part of Your Certificate. The effective date of this change is the latter of the effective date of this Certificate or the date this benefit is added to the Policy. Except as modified below, all Policy terms, conditions, and limitations apply. Subject to the terms below, a benefit is payable for loss due to the covered Dependent Spouse's Accidental Death or Accidental Bodily Injury if shown on the Schedule of Benefits. The loss must: (a) occur within 180 days after the accident which caused the loss; and (b) be due to an accident which occurs while the covered Dependent Spouse is insured under the Benefit. If the covered Dependent Spouse suffers multiple losses in the same accident, Our liability will be limited to payment for the one type of loss which provides the greatest benefit. The amount of benefit payable for each type of loss is: LOSS BENEFIT OTHER THAN BENEFIT FOR A COMMON CARRIER COMMON ACCIDENT ACCIDENT Loss of Life Full Amount 2 Times Full Amount Loss of both hands Full Amount 2 Times Full Amount Loss of both feet Full Amount 2 Times Full Amount Loss of sight of both eyes Full Amount 2 Times Full Amount Loss of one hand and one foot Full Amount 2 Times Full Amount Loss of one hand or one foot Full Amount 2 Times Full Amount and sight of one eye Loss of one hand One-Half of the Full Amount Full Amount Loss of one foot One-Half of the Full Amount Full Amount Loss of sight of one eye One-Half of the Full Amount Full Amount Loss of thumb and index finger One-Fourth of the One-Half of the of the same hand Full Amount Full Amount


COVERED DEPENDENT SPOUSE (continued)

GN-70051-07 EM ADDS 5/2005 47

PARALYSIS BENEFIT The paralysis must be determined by a Qualified Practitioner to be permanent, complete and irreversible. LOSS BENEFIT OTHER THAN BENEFIT FOR A COMMON CARRIER COMMON ACCIDENT ACCIDENT Quadriplegia Full Amount 2 Times Full Amount Paraplegia One-half of the Full Full Amount Amount Hemiplegia One-half of the Full Full Amount Amount REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if applicable, are also shown on the Schedule of Benefits. If the covered Dependent Spouse's loss occurs on or after a reduction age is effective, the full amount shown on the Schedule of Benefits will be reduced by the corresponding reduction percentage shown. This means that if the accident occurs before the effective date of the reduction age, but the covered Dependent Spouse's loss occurs on or after the effective date of the reduction age, We will pay the benefit based on the reduced amount. A reduction age is effective on the first day of a calendar month following the date the covered Dependent Spouse attains that age. TO WHOM PAYABLE Benefits for Accidental Dismemberment, or Paralysis are payable to the Employee. Benefits for Accidental Death are payable in accordance with the Dependent Term Life Insurance Benefits provision - Beneficiary section. DEFINITIONS • ACCIDENTAL DEATH

Accidental Death means loss of life which results directly from: − Bodily Injury; − Infection caused by Bodily Injury, or infection resulting from accidental ingestion of

contaminated substances; or − Accidental drowning.



GN-70051-07 EM ADDS 5/2005 48

• ACCIDENTAL DISMEMBERMENT

Accidental Dismemberment means complete, permanent and irretrievable loss, resulting directly from Bodily Injury of: − A hand or foot by severance at or above the wrist or ankle joint; or − The sight of an eye.

• COMMON CARRIER ACCIDENT

Common Carrier Accident means a covered accident Bodily Injury that is sustained while riding as a fare-paying passenger (not a pilot, operator or crew member) in or on, boarding or getting of from a common carrier.

• COMMON CARRIER

Common Carrier means any land, air, water vehicle operated under a valid licensed to transport passengers for hire.

• QUADRIPLEGIA

Quadriplegia means total paralysis of all four limbs. • PARAPLEGIA

Paraplegia means total paralysis of both lower limbs. • HEMIPLEGIA

Hemiplegia means total paralysis of one arm and one leg on the same side of the body. SEAT BELT, AIRBAG - HELMET BENEFIT The Seat Belt, Airbag, Helmet Benefit is payable if You die as a direct result of Bodily Injury sustained in an automobile or motorcycle accident as a passenger or driver. In the event of a automobile accident the benefit is payable if: • A copy of the police report is submitted with the claim; • You were seated in a seat equipped with a properly functioning airbag; • You were wearing a properly fastened seat belt in the correct position; and • The correct position of the seat belt was certified by the investigating officer or indicated in the police

report



GN-70051-07 EM ADDS 5/2005 49

We will increase Your Accidental Death benefit by 10%, up to $10,000 but not less than $1,000 for using Your seat belt. Additionally, We will increase Your Accidental Death benefit by 5%, up to $5,000, but not less than $500 for the properly functioning airbag. In the event of a motorcycle accident the benefit is payable if: • A copy of the policy report is submitted with the claim; • You were wearing a properly fitted and fastened motorcycle helmet; and • The use of properly fitted and fastened motorcycle helmet was certified by the investigating officer or

indicated in the police report. We will increase Your Accidental Death benefit by 10%, up to $10,000, but not less than $1,000 for wearing a properly fitted and fastened motorcycle helmet. If We are unable to determine whether You had been wearing a properly fastened seat belt, seated in a seat equipped with a functioning airbag, or wearing a properly fitted and fastened motorcycle helmet. We will pay a benefit of $1,000 to Your beneficiary. We will increase Your Accidental Death benefit by 10%, up to $10,000 but not less than $1,000 for using Your seat belt. Additionally, We will increase Your Accidental Death benefit by 5%, up to $5,000, but not less than $500 for the properly functioning airbag. DEFINITIONS • AUTO Auto means a four-wheel passenger car, station wagon, sport utility vehicle, truck or van-type car. It must be licensed for use on public highways. It includes a care owned or leased by a group certificate holder. • MOTOR CYLCE Motor cycle means a two wheel passenger motorcycle. It must be licensed for use on public highways. It includes a motorcycle owed or leased by a group certificate holder. LIMITATIONS Accidental Death or Bodily Injury benefits DO NOT cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane

or insane; • The voluntary taking of any sedative, drug, alcohol, poison or inhalation of any gas unless taken or

inhaled as prescribed or administered by a Qualified Practitioner;



GN-70051-07 EM ADDS 5/2005 50

• Being intoxicated or under the influence of any unlawful substance, narcotic or hallucinogenic unless

administered on the advice of a Qualified Practitioner; • Travel or flight in a device of any type for aerial navigation, except as a fare-paying passenger of a

licensed passenger airline; • Commission or attempt to commit a civil or criminal battery or felony; • Driving or operating while legally intoxicated or under the influence of illegal substance.

Intoxication means that blood alcohol content or the results of other means of testing blood alcohol level meet or exceeds the legal presumption of intoxication under the law of the state where the accident took place;

• Driving or operating a motorized vehicle without a valid drivers’ license; • Driving or operating a motorized vehicle in excess of the legal speed limit; • Service in any armed forces, except if You are in temporary active duty as a reservist for military

training that lasts 30 days or less; • Bodily Injury or Sickness contributed to or caused by:

− War or any act of war, whether declared or not; or

− Any act of armed conflict, or any conflict involving armed forces of any authority; • Bodily or mental infirmity, or its related surgical or medical treatment or any infection unless the

direct result of Bodily Injury, or unless resulting from the accidental ingestion of a contaminated substance;

• Participation in a riot, rebellion or insurrection. Participation means taking an active part in common with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law; or

• Participation in hazardous sports, including but not limited to: Bungee jumping, motorized vehicle racing, rock climbing, rodeo events, scuba diving, skydiving, parachuting, hang gliding, or ballooning.


SUPPLEMENTAL BENEFIT PORTABILITY PRIVILEGE

GN-70057-07 EM PORTE 51

This benefit is attached to and made a part of Your Certificate. The effective date of this change is the latter of the effective date of this Certificate or the date this benefit is added to the Policy. Except as modified below, all Policy terms, conditions, and limitations apply. APPLICABILITY This provision applies only to contributory Voluntary Term Life Insurance. It DOES NOT apply to any other coverages. DEFINITION As used in this provision, the term Port means to elect a continuation of Your contributory Voluntary Term Life Insurance. ELIGIBILITY TO "PORT" An Employee may elect to continue all or part of the Employee's Voluntary Term Life Insurance and Dependent Voluntary Term Life Insurance, if applicable, by electing a continuation of coverage, subject to the following terms and restrictions: • No Employee may elect to continue coverage unless the Employee has been covered by this group

Plan, or the one it replaced, for Voluntary Term Life Insurance for at least 31 consecutive days prior to the date the Employee's coverage under this Plan ends.

• The Employee is not allowed to convert coverage and elect to Port at the same time. If a situation

arises in which the Employee would be eligible to both convert and Port, he or she may only exercise one of these privileges. You may never be insured under both a converted policy and a portable certificate of coverage at the same time.

• The Employee may not Port his or her coverage, or coverage for any Dependents if the Employee

has reached his or her 70th birthday on the day his or her coverage ends under this Plan. • An Employee may not Port a Dependent spouse's coverage if the Dependent spouse has reached his

or her 70th birthday on the day his or her coverage ends under this Plan. • An Employee may not Port coverage if he or she has received a benefit under the Accelerated Death

Benefit provision. • An Employee may Port his or her coverage if coverage under this Plan ends for any reason other

than:

− Termination of employment due to Total Disability; − Failure to pay any required premium; or − The Employer terminates the Policy.

SUPPLEMENTAL BENEFIT PORTABILITY PRIVILEGE

GN-70057-07 EM PORTE 52

AMOUNT OF PORTABLE COVERAGE An Employee may Port the full amount of his or her Voluntary Term Life Insurance amount as of the day his or her coverage under this Plan ends, or any lesser amount in increments of $20,000 equal to a multiple of the Employee's basic annual compensation in force on the date employment ends. An Employee may Port the full amount of his or her Dependent Voluntary Term Life Insurance amount(s) as of the day the Employee's coverage under this Plan ends. The Employee may Port any lesser amount of Dependent Voluntary Term Life Insurance in increments of $10,000. In no event will a Dependent's amount be more than 50% of the Employee's amount. The amount of the coverage You may Port will be reduced or terminated according to the Reduction for Age Schedule, if applicable, shown on Your Schedule of Benefits. An Employee may Port: • The Employee's insurance amount only; • The Employee's insurance amount and the Dependent spouse insurance amount; • The Employee's insurance amount and insurance amount of all of the covered Dependents; or • The Employee's insurance amount and the insurance amount of the covered Dependent children. No other combinations of Ported insurance amounts will be allowed. To be eligible for portability, a Dependent must be covered as of the day the Employee's coverage under this Plan ends. THE PORTABILITY CERTIFICATE OF COVERAGE The Portability Certificate of Coverage provides group Term Life Insurance. It does not provide any other benefits. The benefits provided by the Portability Certificate of Coverage may not be identical to the benefits provided by this Plan. HOW TO PORT The Employee must apply to Us in writing, and pay the required premium to receive a Portability Certificate of Coverage. The Employee has 31 days from the date coverage under this Plan ends to apply. No proof of insurability is required.


DISCOUNT DISCLOSURE

Discount 53

From time to time, We may offer or provide access to discount programs to persons who become insureds. In addition, We may arrange for third party service providers such as pharmacies, optometrists, dentists and alternative medicine providers, to provide discounts on goods and services to persons who become insureds. Some of these third party service providers may make payments to Us when insureds take advantage of these discount programs. These payments offset the cost to Us of making these programs available and may help reduce the costs of Your plan administration. Although We have arranged for third parties to offer discounts on these goods and services, these discount programs are not insured benefits under this Policy. The third party service providers are solely responsible to insureds for the provision of any such goods and/or services. We are not responsible for any such goods and/or services, nor are We liable if vendors refuse to honor such discounts. Further, We are not liable to insureds for the negligent provision of such goods and/or services by third party service providers. Discount programs may not be available to persons who "opt out" of marketing communications and where otherwise restricted by law.

Toll Free: 800-558-4444 1100 Employers Blvd. Green Bay,WI 54344 www.humana.com

INSURED BY

HUMANA INSURANCE COMPANY

Form 1643 IN 12/16

NOTICE OF PROTECTION PROVIDED BY THE INDIANA LIFE AND

HEALTH INSURANCE GUARANTY ASSOCIATION

This notice provides a brief summary of the Indiana Life and Health Insurance Guaranty Association (“ILGHIGA”) and the protection it provides for policyholders. ILHIGA was established to provide protection to policyholders in unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations. If this should happen, ILHIGA will typically arrange to continue coverage and pay claims, in accordance with Indiana law, with funding from assessments paid by other insurance companies. Basic Protections Currently Provided by ILHIGA Generally, an individual is covered by ILHIGA if the insurer was a member of the ILHIGA and the Individual lives in Indiana at the time the insurer is ordered into liquidation with a finding of insolvency. The coverage limits below apply only for companies placed in rehabilitation or liquidation on or after January 1, 2013. Life Insurance

• $300,000 in death benefits • $100,000 in cash surrender or withdrawal values

Health Insurance

• $500,000 in basic hospital, medical and surgical or major medical insurance benefits • $300,000 in disability and long term care insurance • $100,000 in other types of health insurance

Annuities

• $250,000 in present value of annuity benefits (including cash surrender or withdrawal values) • $5,000,000 for covered unallocated annuities

The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000. Special rules may apply with regard to basic hospital, medical and surgical or major medical insurance benefits. The protections listed above apply only to the extent that benefits are payable under covered Policy(s). In no event will the ILHIGA provide benefits greater than those given in the life, annuity, or health insurance policy or contract. The statutory limits on ILHIGA coverage have changed over the years and coverage in prior years may not be the same as that set forth in this notice. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or variable annuity contract. To learn more about the protections provided by ILHIGA, please visit ILHIGA website at www.inlifega.org or contact: Indiana Life and Health Insurance Indiana Department of Insurance Guaranty Association 311 West Washington Street, Suite 103 3502 Woodview Trace Suite 100 Indianapolis, IN 46204 Indianapolis, IN 46268 317-232-2385 317-636-8204 The policy or contract that this notice accompanies might not be fully covered by ILHIGA and even if coverage is currently provided, coverage is (a) subject to substantial limitations and exclusions

Form 1643 IN 12/16

(some of which are described above), (b) generally conditioned on continued residence in Indiana, and (c) subject to possible change as a result of future amendments to Indiana law and court decisions. Complaints to allege a violation of any provision of the Indiana Life and Health Insurance Guaranty Association Act must be filed with the Indiana Department of Insurance, 311 W. Washington Street, Suite 103, Indianapolis, IN 46204; (telephone) 317-232-2385. Insurance companies and agents are not allowed by Indiana law to use the existence of ILHIGA or its coverage to encourage you to purchase any form of insurance (IC 27-89-8-18(a)). When selecting an insurance company, you should not rely on ILHIGA coverage. If there is any inconsistency between this notice and Indiana law, Indiana law will control. Questions regarding the financial condition of a company or your life, health insurance policy or annuity should be directed to your insurance company or agent.

NOTICE TO POLICYHOLDERS REGARDING FILING COMPLAINTS WITH THE DEPARTMENT OF INSURANCE

Questions regarding your policy or coverage should be directed to: Humana Insurance Company 1-800-558-4444 If you (a) need the assistance of the governmental agency that regulates insurance; or (b) have a complain you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email: State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, IN 46204 Consumer Hotline: 1-800-622-4461; or 1-317-232-2395 Complaints can be filed electronically at www.in.gov/idoi.

Notices

The following pages contain important information about Humana's claims procedures and certain federal laws. There may be differences between the Certificate of Insurance and this Notice packet. There may also be differences between this notice packet and state law. The Plan participant is eligible for the rights more beneficial to the participant. This section includes notices about: Claims and Appeal Procedures Federal Legislation Claims Procedures Appeals of Adverse Determinations

Your Rights Under ERISA Privacy and Confidentiality Statement Discrimination Notice

LIFE INSURANCE WAVIER OF PREMIUM AND SHORT TERM DISABILITY CLAIMS PROCEDURES

CLAIMS PROCEDURES Definitions Humana: Humana Insurance Company Claimant: A covered person (or authorized representative) who files a claim. Submitting a Claim This section describes how a Claimant files a claim for plan benefits. A request for a waiver of Life Insurance premium due to a total disability will be treated as a claim. A claim must be filed in writing and delivered by mail, postage prepaid, by FAX or e-mail. Claims will be not be deemed submitted for purposes of these procedures unless and until received at the correct address. Claims submissions must be in a format acceptable to Humana and compliant with any legal requirements. Claims not submitted in accordance with the requirements of applicable federal law respecting privacy of protected health information and/or electronic claims standards will not be accepted by Humana. Claims submissions must be timely. Claims must be filed as soon as reasonably possible, and in no event later than the period of time described in the benefit plan document. Claims submissions must be submitted on the claims form provided by Humana and available from your employer. The claim form must be complete. Authorized Representatives A covered person may designate an authorized representative to act on his or her behalf in pursuing a benefit claim or appeal. The authorization must be in writing and authorize disclosure of health information. If a document is not sufficient to constitute designation of an authorized representative, as determined by Humana, the plan will not consider a designation to have been made. An assignment of benefits does not constitute designation of an authorized representative. Covered persons should carefully consider whether to designate an authorized representative. Circumstances may arise under which an authorized representative may make decisions independent of the covered person, such as whether and how to appeal a claim denial. Claims Decisions Humana will provide notice of a favorable or adverse determination within a reasonable time but no later than 45 days after the plan receives the claim.

This period may be extended an additional 30 days, if Humana determines the extension is necessary due to matters beyond the plan’s control. Before the end of the initial 45-day period, Humana will notify the affected Claimant of the extension, the circumstances requiring the extension and the date by which the plan expects to make a decision. The review period may be extended for another 30 days, if before the end of the first 30-day extension, the plan determines a second extension is necessary due to matters beyond the plan’s control. Before the end of the first 30-day extension, Humana will notify the affected Claimant of the additional extension, the circumstances requiring the extension and the date by which the plan expects to make a decision. If the reason for the extension is because Humana does not have enough information to decide the claim, the notice of extension will describe the required information, and the Claimant will have at least 45 days from the date the notice is received to provide the specified information. Humana will make a decision on the earlier of the date on which the Claimant responds or the expiration of the time allowed for submission of the requested information. Initial Denial Notices Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e-mail, as appropriate, within the time frames noted above. A claims denial notice will convey the specific reason for the adverse determination and the specific plan provisions upon which the determination is based. The notice will also include a description of any additional information necessary to perfect the claim and an explanation of why such information is necessary. The notice will disclose if any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of the rule, protocol or similar criterion will be provided to Claimants, free of charge, upon request. APPEALS OF ADVERSE DETERMINATIONS A Claimant must appeal an adverse determination within 180 days after receiving written notice of the denial (or partial denial). An appeal may be made by a Claimant by means of written application to Humana, in person, or by mail, postage prepaid. Determination of appeals of denied claims will be conducted promptly, will not defer to the initial determination and will not be made by the person who made the initial adverse claim determination or a subordinate of that person. On appeal, a Claimant may review pertinent documents and may submit issues and comments in writing. A Claimant on appeal may, upon request, discover the identity of medical or vocational experts whose advice was obtained on behalf of the plan in connection with the adverse determination being appealed, as permitted under applicable law. If the claims denial is based in whole, or in part, upon a medical judgment, the person deciding the appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The consulting health care professional will not be the same person who decided the initial appeal or a subordinate of that person.

Time Periods for Decisions on Appeal Appeals of claims denials will be decided and notice provided within 45 days after Humana receives the appeal request. This period may be extended an additional 45 days, if Humana determines the extension is necessary due to matters beyond the plan's control. Before the end of the initial 45-day period, Humana will notify the affected Claimant of the extension, the circumstances requiring the extension and the date by which the plan expects to make a decision. Appeals Denial Notices Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e-mail, as appropriate, within the time periods noted above. A notice that a claim appeal has been denied will include: • The specific reason or reasons for the adverse determination. • Reference to the specific plan provision upon which the determination is based. • If any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of

the rule, protocol or similar criterion will be provided to the Claimant, free of charge, upon request. • A statement describing any voluntary appeal procedures offered by the plan and the claimant's right

to obtain the information about such procedures, and a statement about the Claimant's right to bring an action under ERISA.

In the event an appealed claim is denied, the Claimant will be entitled to receive without charge reasonable access to and copies of any documents, records or other information that: • Was relied upon in making the determination. • Was submitted, considered or generated in the course of making the benefit determination, without

regard to whether such document, record or other information was relied upon in making the benefit determination.

• Demonstrates compliance with the administrative processes and safeguards required in making the

determination. • Constitutes a statement of plan policy or guidance with respect to the plan concerning the denied

benefit, without regard to whether the statement was relied on in making the benefit determination. EXHAUSTION OF REMEDIES Upon completion of the appeals process under this section, a Claimant will have exhausted his or her administrative remedies under the plan. If Humana fails to complete a claim determination or appeal within the time limits set forth above, the claim shall be deemed to have been denied and the Claimant may proceed to the next level in the review process.

After exhaustion of remedies, a Claimant may pursue any other legal remedies available, which may include bringing civil action under ERISA section 502(a) for judicial review of the plan's determination. Additional information may be available from the local U.S. Department of Labor Office. LEGAL ACTIONS AND LIMITATIONS No lawsuit may be brought with respect to plan benefits until all remedies under the plan have been exhausted. No lawsuit with respect to plan benefits may be brought after the expiration of the applicable limitations period stated in the benefit plan document. If no limitation is stated in the benefit plan document, then no such suit may be brought after the expiration of the applicable limitations under applicable law. YOUR RIGHTS UNDER ERISA Under the Employee Retirement Income Security Act of 1974 (ERISA), all plan participants covered by ERISA are entitled to certain rights and protections, as described below. Notwithstanding anything in the group health plan or group insurance policy, following are a covered person’s minimum rights under ERISA. ERISA requirements do not apply to plans maintained by governmental agencies or churches. Information about the Plan and Benefits Plan participants may: 1. Examine, free of charge, all documents governing the plan. These documents are available in the

plan administrator's office. 2. Obtain, at a reasonable charge, copies of documents governing the plan, including a copy of any

updated summary plan description and a copy of the latest annual report for the plan (Form 5500), if any, by writing to the plan administrator.

3. Obtain, at a reasonable charge, a copy of the latest annual report (Form 5500) for the plan, if any, by writing to the plan administrator.

As a plan participant, you will receive a summary of any material changes made in the plan within 210 days after the end of the plan year in which the changes are made unless the change is a material reduction in covered services or benefits, in which case you will receive a summary of the material reduction within 60 days after the date of its adoption. If the plan is required to file a summary annual financial report, you will receive a copy from the plan administrator. Responsibilities of Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the plan. These people, called 'fiduciaries" of the plan, have a duty to act prudently and in the interest of plan participants and beneficiaries. No one, including an employer, may discharge or otherwise discriminate against a plan participant in any way to prevent the participant from obtaining a benefit to which the participant is otherwise entitled under the plan or from exercising ERISA rights.

Claims Determinations If a claim for a plan benefit is denied or disregarded, in whole or in part, participants have the right to know why this was done, to obtain copies of documents relating to the decision without charge and to appeal any denial within certain time schedules. Enforce Your Rights Under ERISA, there are steps participants may take to enforce the above rights. For instance, if a participant requests a copy of plan documents does not receive them within 30 days, the participant may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $ 110 a day until the participant receives the materials, unless the materials were not sent because of reasons beyond the control of the plan administrator. If a claim for benefits is denied or disregarded, in whole or in part, the participant may file suit in a state or Federal court. In addition, if the participant disagrees with the plan's decision, or lack thereof, concerning the qualified status of a domestic relations order or a medical child support order, the participant may file suit in Federal court. If plan fiduciaries misuse the plan's money, or if participants are discriminated against for asserting their rights, they may seek assistance from the U.S. Department of Labor, or may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If the participant is successful, the court may order the person sued to pay costs and fees. If the participant loses, the court may order the participant to pay the costs and fees. Assistance with Questions Contact the group health plan human resources department or the plan administrator with questions about the plan. Contact the nearest area office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210 with questions about ERISA rights. Call the publications hotline of the Employee Benefits Security Administration to obtain publications about ERISA rights. PRIVACY AND CONFIDENTIALITY STATEMENT We understand the importance of keeping your personal and health information private (PHI). PHI includes both medical information and individually identifiable information, such as your name, address, telephone number or social security number. We are required by applicable federal and state law to maintain the privacy of your PHI. Under both law and our policies, we have a responsibility to protect the privacy of your PHI. We: • Protect your privacy by limiting who may see your PHI; • Limit how we may use or disclose your PHI; • Inform you of our legal duties with respect to your PHI; • Explain our privacy policies; and • Strictly adhere to the policies currently in effect. We reserve the right to change our privacy practices at any time, as allowed by applicable law, rules and regulations. We reserve the right to make changes in our privacy practices for all PHI that we maintain, including information we created or received before we made the changes. When we make a significant change in our privacy practices, we will send notice to our health plan subscribers. For more information about our privacy practices, please contact us.

As a covered person, we may use and disclose you PHI, without your consent/authorization, in the following ways: Treatment: we may disclose your PHI to a health care practitioner, a hospital or other entity which asks for it in order for you to receive medical treatment. Payment: we may use and disclose your PHI to pay claims for covered services provided to you by health care practitioners, hospitals or other entities. We may use and disclose your PHI to conduct other health care operations activities. It has always been our goal to ensure the protection and integrity of your personal and health information. Therefore, we will notify you of any potential situations where your identification would be used for reasons other than treatment, payment and health plan operations.

Discrimination is Against the Law

Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Humana Inc. and its subsidiaries do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Humana Inc. and its subsidiaries provide: • Free auxiliary aids and services, such as qualified sign language interpreters, video remote

interpretation, and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate.

• Free language services to people whose primary language is not English when those services are

necessary to provide meaningful access, such as translated documents or oral interpretation. If you need these services, call 1-855-448-6982 or, if you use a TTY, call 711. If you believe that Humana Inc. and its subsidiaries have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Discrimination Grievances P.O. Box 14618 Lexington, KY 40512-4618 If you need help filing a grievance, call 1-855-448-6982 or if you use a TTY, call 711. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

http://www.hhs.gov/ocr/office/file/index.html

Multi-Language Interpreter Services

GN-70054-07 EM

L C EMPLOYER: FLOYD COUNTY GOVERNMENT

GROUP NUMBER: 671728

PORTABILITY CERTIFICATE OF INSURANCE

Humana Insurance Company

This Certificate is not an insurance policy. It is an outline of the insurance provided by the group policy and it does not extend or change the coverage afforded by such group policy. The insurance described by this Certificate is subject to all the provisions, terms, exclusions and conditions of the group policy. This Certificate supersedes and replaces any Certificate previously issued under the provisions of the group policy.


GROUP INSURANCE CERTIFICATE

GN-70054-07 EM CP

POLICYHOLDER (EMPLOYER): FLOYD COUNTY GOVERNMENT GROUP NUMBER: 671728 BENEFITS EFFECTIVE DATE Employee Voluntary Life for Employee 01/01/2018 Dependent Voluntary Life for Employee and Covered Dependents 01/01/2018

TABLE OF CONTENTS

GN-70054-07 EM TAB

SCHEDULE OF BENEFITS DEFINITIONS WHO IS COVERED GENERAL PROVISIONS EMPLOYEE VOLUNTARY TERM LIFE INSURANCE BENEFITS DEPENDENT VOLUNTARY TERM LIFE INSURANCE BENEFITS DISCOUNT DISCLOSURE

SCHEDULE OF BENEFITS

GN-70054-07 EM ERSCBPORT 4

VOLUNTARY TERM LIFE INSURANCE

VOLUNTARY TERM LIFE INSURANCE BENEFIT - As shown on each Covered Person's Schedule of Benefits THE TERM LIFE INSURANCE BENEFIT IS REDUCED TO THE FOLLOWING: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64


GN-70054-07 EM ERSCBPORTS 5

VOLUNTARY DEPENDENT SPOUSE TERM LIFE INSURANCE

BENEFIT VOLUNTARY DEPENDENT SPOUSE TERM LIFE INSURANCE BENEFIT - As shown on each Covered Person's Schedule of Benefits THE DEPENDENT SPOUSE TERM LIFE INSURANCE BENEFIT IS REDUCED TO THE FOLLOWING: Reduced by 35% AT AGE 65 based on the amount of Term Life Insurance in force at age 64 Reduced by 55% AT AGE 70 based on the amount of Term Life Insurance in force at age 64 Reduced by 70% AT AGE 75 based on the amount of Term Life Insurance in force at age 64 Reduced by 80% AT AGE 80 based on the amount of Term Life Insurance in force at age 64 Reduced by 85% AT AGE 85 based on the amount of Term Life Insurance in force at age 64


GN-70054-07 EM ESCBPORTC 6

DEPENDENT CHILD VOLUNTARY TERM LIFE INSURANCE BENEFIT DEPENDENT CHILD VOLUNTARY - BIRTH THROUGH 14 DAYS .......................................$ 0 DEPENDENT CHILD VOLUNTARY - 15 DAYS UP TO 6 MONTHS .......................................$500 DEPENDENT CHILD VOLUNTARY - FROM AGE 6 MONTHS TO ATTAINMENT OF LIMITING AGE..............................................................................................................................................$5,000

DEFINITIONS

IN-70054-07 EM PORT 8

The following are definitions of terms as they are used in this Certificate. Defined terms are printed in bold face type wherever found in this Certificate. BODILY INJURY Bodily Injury means injury due directly to a specific accident, independent of all other causes. Muscle strain due to athletic or physical activity or bodily damage resulting from infection, is considered a Sickness. COVERED PERSON Covered Person means the Employee and/or the Employee's covered Dependents. DEPENDENT Dependent means a covered Employee's: • Legally recognized spouse; or • Unmarried natural blood related child, step-child, legally adopted child or child placed with

the Employee for the purpose of adoption whose age is less than the limiting age. Dependent DOES NOT mean a grandchild, great grandchild, or foster child. Each child must:

− Meet all of the qualifications of a Dependent as determined by the Internal Revenue

Service; and

− Be declared on and legally qualify as a Dependent on the Employee's federal personal income tax return filed for each year of coverage.

The limiting age for each Dependent child is: • The child's 26th birthday; or • The child's 26th birthday if such child is in regular full-time attendance at an accredited

secondary school, college or university. The Dependent child must be enrolled for sufficient course credits to maintain full-time status as defined by that school. A Dependent child continues to be eligible for coverage for up to four months following the close of a school term only if enrolled as a full-time student for the following school term.

You must furnish satisfactory proof to Us upon Our request that the above conditions continuously exist. If satisfactory proof is not submitted to Us, the child's coverage will not continue beyond the last date of eligibility. A covered Dependent child who becomes an employee eligible for other group coverage through employment is no longer eligible as a Dependent for coverage under this Policy.


IN-70054-07 EM PORT 9

A covered Dependent child who attains the limiting age WHILE INSURED under this Policy remains eligible for Benefits if: • Mentally retarded or permanently physically handicapped; • Incapable of self-sustaining employment; • The child meets all of the qualifications of a Dependent as determined by the Internal

Revenue Service; • Declared on and legally qualified as a Dependent on the Employee's federal personal

income tax return filed for each year of coverage; and • Unmarried. You must furnish satisfactory proof to Us upon Our request that the above conditions continuously exist on and after the date the limiting age is reached. After two years from the date the first proof was furnished, We may not request such proof more often than annually. If satisfactory proof is not submitted to Us, the child's coverage will not continue beyond the last date of eligibility. EMPLOYEE Employee means a person who chose to Port his or her Employee Voluntary Term Life Insurance coverage. EMPLOYER Employer means the Policyholder of this Group Insurance Plan, or any subsidiary described in the Employer Group Application. POLICYHOLDER The Legal Entity named as the Policyholder on the face page of the Policy. PORT Port means to elect a continuation of Your contributory Voluntary Term Life Insurance. PRIOR PLAN Prior Plan means the group life insurance Policy, issued by Us, from which You Ported coverage to this Plan.


IN-70054-07 EM PORT 10

QUALIFIED PRACTITIONER Qualified Practitioner means a practitioner, professionally licensed by the appropriate state agency to diagnose or treat a Bodily Injury or Sickness, and who provides services within the scope of that license. A Qualified Practitioner does not include a practitioner who resides in Your home or is Your Family Member. SICKNESS Sickness means a disturbance in function or structure of Your body which causes physical signs or symptoms which, if left untreated, will result in a deterioration of the health state of the structure or system(s) of Your body. WE, US, and OUR We, Us, and Our means the Insurance Company as shown on the cover page of this Certificate. YOU and YOUR You and Your means any Covered Person.

WHO IS COVERED WHO IS ELIGIBLE FOR COVERAGE The Employee is eligible for coverage if covered under the Employer's plan, and the Employee is under the age of 70 years. The Employee's Dependents are covered if they were covered under the Employer's plan and the Employee applied and paid premium to Port the Dependent coverage. No other persons may become covered under this Plan after the Effective Date, except for the following: • The Employee's newborn child; or • A child legally adopted by the Employee or a child placed in the Employee's home for the

purpose of adoption by the Employee. If You wish to enroll the newborn child, the adopted child or the child placed for adoption, You must enroll the child within 31 days from the date of birth, date of adoption or date of placement for adoption, as applicable, and pay any required premium. Refer to Your Schedule of Benefits for benefits available.

WHO IS COVERED (continued)

IN-70054-07 EM PORT 11

EFFECTIVE DATE The Employee must complete and sign an enrollment form. This must be done within the time period allowed to Port under the Employer's plan. The enrollment form and the premium must be received by Us for coverage to be in effect. In no event will coverage be in effect before the enrollment form and premium are received by Us and the enrollment form is accepted by Us. If We accept the enrollment form, Your coverage is in effect on the day immediately following the date Your coverage terminated under the Employer's plan. PREMIUM You must pay premium for this insurance. Premium must be paid on or before the first day of each premium period. Premium period means a annual basis. Premium must be received by Us to be considered paid. Coverage is in effect until the next premium due date. If We accept premium from You immediately prior to or after a date Your coverage would otherwise terminate, You are covered until the end of the period for which premium is paid. You have the right to cancel this coverage before that date. You will be refunded any unused premium up to the cancellation date. GRACE PERIOD If You do not pay Your premium on or before the premium due date, You have a Grace Period to pay it. The Grace Period is 31 days immediately following the premium due date. You are insured during the Grace Period. If You do not pay the premium before the end of the 31 days, Your coverage terminates at the end of the Grace Period. If You die during the Grace Period and You do not pay the premium, the amount of premium will be deducted from the benefits payable. The Grace Period does not apply if You write Us at least 15 days before a premium due date that You are canceling coverage. WHEN COVERAGE TERMINATES Your coverage automatically terminates on the earliest of the following: • The last day of the period of time for which You paid premium, subject to the Grace Period; • For a Dependent, the date that person no longer satisfies the definition of Dependent in this

certificate; • For a Dependent Spouse, the date they attain the age of 70 years; • The date the Employee attains the age of 70 years; • The date the Employee becomes re-employed with the Employer; • For a Dependent, the date that the Employee's coverage ends;

WHO IS COVERED (continued)

IN-70054-07 EM PORT 12

• The date You enter full-time military, naval or air service except that termination will not occur if You are in temporary active duty as a reservist for military training that lasts 30 days or less;

• The date the Employee requests termination of insurance to be effective for the Employee or

Dependents; • The date the Employer's Policy terminates; or • The date the Employer terminates the Portability Provision. YOU ARE RESPONSIBLE TO ADVISE US OF ANY CHANGES IN ELIGIBILITY INCLUDING THE LACK OF ELIGIBILITY OF ANY COVERED PERSON. COVERAGE WILL NOT CONTINUE BEYOND THE LAST DATE OF ELIGIBILITY REGARDLESS OF THE LACK OF NOTICE TO US.

GENERAL PROVISIONS Written notice of claim must be given within 30 days after the date of loss covered by this Policy, or as soon thereafter as is reasonably possible. Notice may be given at Our address shown on the back cover of the Certificate. Notice should include Your name and the name(s) of Your Dependent(s) and Your Policy number. CLAIM FORMS Upon receipt of notice of claim, We will send You the forms for filing proof of loss. If the forms are not sent to You within 15 days, You will have met the proof of loss requirement by sending Us a written statement of the nature and extent of the loss within the time limit stated in the Proof of Loss provision. PROOF OF LOSS You must give written proof of loss within 90 days after the date of loss. Your claim will not be reduced or denied if it was not reasonably possible to give such proof. In any event, written notice must be given within one year after the date proof of loss is otherwise required, except if You were legally incapacitated. TIME OF PAYMENT OF CLAIMS Payments due under the Policy will be paid immediately upon receipt of written proof of loss.


IN-70054-07 EM PORT 13

INCONTESTABILITY After You are insured without interruption for two years, We cannot contest the validity of Your coverage except for: • Nonpayment of premium; • Your ineligibility under the Policy; • Any Policy provision; • Any fraudulent misrepresentation made by You; or • Any defenses We may have by law. No statement made by You can be contested unless it is in a written form signed by You. A copy of the form must be given to You or Your beneficiary. This provision only limits Our right to void Your coverage after You have been insured without interruption for two years. TIME LIMIT ON CERTAIN DEFENSES A claim will not be reduced or denied after two years from the effective date of the benefit because a disease or physical condition not excluded and causing the loss existed before the benefit effective date. CLERICAL ERROR, MISSTATEMENT OF AGE OR SEX If it is determined that information about You or Your Dependents was omitted or misstated in error, the amount of insurance for which You are properly eligible will be in effect. An equitable premium adjustment will be made. This provision applies equally to You and to Us. RIGHT TO COLLECT NEEDED INFORMATION You must cooperate with Us and when asked, assist Us by: • Authorizing the release of medical information including the names of all providers from

whom You received medical attention; • Providing information regarding the circumstances of Your injury or accident; and • Providing information about other insurance coverage and benefits.


IN-70054-07 EM PORT 14

AUTOPSY We may have an autopsy performed unless prohibited by law. LEGAL ACTIONS You cannot bring an action at law or equity to recover a claim until 60 days after the date written proof of loss is made. You cannot bring such action more than three years after such proof of loss is made. CONFORMITY WITH STATE STATUTES Any provisions which, on the Policy effective date, are in conflict with the laws of the state in which the Policy is issued are amended to conform to the minimum requirements of those laws. ASSIGNMENT OF BENEFITS FOR LIFE COVERAGE You have the right to absolutely assign all of Your rights and interest under the Policy including, but not limited to, the following: • The right to make any contributions required to keep the insurance in force; • The privilege of converting; and • The right to name and change beneficiary. If an Irrevocable beneficiary has been designated, Assignment of Benefit will not be allowed. No absolute assignment of rights and interest shall be binding on Us until and unless the original or certified copy of the form documenting the absolute assignment is received and acknowledge by Us at our office. We have no responsibility: • For the validity or effect of any assignment; or • To provide any assignee with notice which We may be obligated to provide You. ENTIRE CONTRACT CHANGES The Policy, including any endorsements and attached papers, constitutes the entire contract of insurance. No change in the Policy is valid until approved by an executive officer of Our company and unless such approval is endorsed or attached to the Policy. No agent has the authority to change the Policy or to remove any of its provisions.


IN-70054-07 EM PORT 15

UNPAID PREMIUMS Upon the payment of a claim under the Policy, any premium then due and unpaid or covered by any note or written order, may be deducted from the claim payment. UNEARNED PREMIUM Upon Your death, the proceeds payable to You or Your estate, shall include premiums paid for any period beyond the end of the Policy-month in which the death occurred. RECOVERY RIGHTS RIGHT OF SUBROGATION If, after payments have been made under this Policy, You or Your covered Dependents has a right to recover damages from a responsible party, We will be subrogated to Your rights to recover. You or Your covered Dependent will do whatever is necessary to enable Us to exercise Our right and will do nothing after loss to prejudice it. If We are precluded from exercising Our Right of Subrogation, We may exercise Our Right of Reimbursement. RIGHT OF REIMBURSEMENT If benefits are paid under this Policy and You or Your covered Dependent recovers from a responsible party by settlement, judgment or otherwise, We have a right to recover from You or Your covered Dependent an amount equal to the amount We paid. ASSIGNMENT OF RECOVERY RIGHTS This Policy contains an exclusion for Sickness or Bodily Injury for which there is Medical Payment/Expense coverage provided or payable under any automobile, homeowner's, premises or other similar coverage. If Your claim against the other insurer is denied or partially paid, We will process Your claim according to the terms and conditions of this Policy. If payment is made by Us on Your behalf, You agree to assign to Us any right You have against the other insurer for medical expenses We pay.

EMPLOYEE VOLUNTARY TERM LIFE INSURANCE BENEFITS

IN-70054-07 EM EPORT 16

BENEFIT The amount of Your Voluntary Term Life Insurance benefit is shown on the Schedule of Benefits. Subject to the terms below, a payment in this amount will be made to the beneficiary named by You. Payment is made when We receive proof that Your death occurred while insured for this benefit. The Voluntary Term Life Insurance has no cash surrender or loan values. REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if any, are shown on the Schedule of Benefits. If Your death occurs on or after a reduction age, the amount of payment will be reduced by the corresponding reduction percentage shown. A reduction in benefits due to age is effective on the first day of the calendar month following the date You attain that age. BENEFICIARY You may name any beneficiary You choose. You may also change a named beneficiary at any time by notifying Us in writing. The change will be effective on the date You sign the form. If We make a payment before receiving the change form, We are released from further liability to the extent of the payment. If a payment is to be made to two or more beneficiaries, but You have not specified the portions payable to each, the payment will be shared equally. If You have not named a beneficiary, or if the beneficiary You named is not alive at Your death, the payment will be made, at Our option, to any one or more of the following: • Your spouse; • Your children; • Your parents; • Your brothers and sisters; or • Your estate. We will rely upon an affidavit to determine benefit payment, unless We receive written notice of valid claim before payment is made. Payment pursuant to the affidavit will release Us from further liability. Any payment made by Us in good faith will fully discharge Us to the extent of such payment. Any amount payable to a minor will be paid to the minor's legal guardian.

EMPLOYEE VOLUNTARY TERM LIFE INSURANCE BENEFITS (continued)

IN-70054-07 EM EPORT 17

NOTICE OF DEATH No payment will be made unless We receive written proof of Your death. In order to receive benefits, written notice of death must be furnished to Us within 12 months after the date of death. If a death claim is filed more than 12 months after the date of death, We must have proof that it was not possible for the claim to be filed within 12 months. LIMITED BENEFITS FOR SELF-INDUCED SICKNESS, SUICIDE, OR SELF-INFLICTED BODILY INJURY In the event of death caused by self-induced Sickness, suicide or intentional self-inflicted Bodily Injury, whether sane or insane, within the first year of Your effective date of Voluntary Term Life coverage under Your Employer's plan, benefits will be limited to the premium paid for this Employee Voluntary Term Life Insurance. LIMITATIONS Benefits do not cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane

or insane, within the first year of Your effective date of Voluntary Term Life coverage under Your Employer's plan. Benefits will be limited to the premium paid for this Employee Voluntary Term Life Insurance;

• The voluntary taking of any sedative or drug or alcohol or inhalation of any gas unless taken or

inhaled as prescribed or administered by a Qualified Practitioner within the first year of Your effective date of Voluntary Term Life coverage under Your Employer's plan. Benefits will be limited toe the premium paid for this Employee Voluntary Term Life Insurance;


licensed passenger airline; • Commission or attempt to commit a civil or criminal battery or felony; • Service in any armed forces, except if You are in temporary active duty as a reservist for military



− Any act of armed conflict, or any conflict involving armed forces of any authority; or

EMPLOYEE VOLUNTARY TERM LIFE INSURANCE BENEFITS (continued)

IN-70054-07 EM EPORT 18

• Participation in a riot, rebellion or insurrection. Participation means taking an active part in common with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law. EMPLOYEE LIFE INSURANCE CONVERSION PRIVILEGE The Employee is entitled to apply for a Conversion Policy of Life Insurance if insurance which has been continued under this section of the Employer's policy terminates or the Employer terminates the Portability Provision. The amount the Employee is entitled to apply for is the lesser of: • The amount of Employee Term Life Insurance that is terminating, LESS the amount of any Life

Insurance for which he or she becomes eligible under any group coverage within 31 days after such termination; or

• $10,000. CONVERSION POLICY The Conversion Policy is issued without evidence of insurability. The Employee must apply for and pay the first premium within 31 days of the termination of the Employee's coverage under the Group Plan. The Conversion Policy will be effective on the 32nd day following such termination. It will be issued on any one of the policy forms, except term insurance, then being issued by Us to individuals of the same age. Premiums for the Conversion Policy will be based on Our current rate for the form, amount of insurance and the Employee's age on the date of issue of the Conversion Policy. NOTICE OF RIGHT TO CONVERT If the Employee has not received notice of his or her right to convert to an individual policy within 15 days before the end of the 31 day conversion period, the Employee will have an additional 15 days from the date the Employee is notified in which to convert; provided, however, that the life insurance coverage under the Policy will not extend beyond the 31st day after termination of the Employee's employment, nor will the Employee's right to convert be extended more than 60 days beyond the Employee's initial 31 day conversion period. DEATH DURING CONVERSION PERIOD If the Employee dies during the 31 day period that he or she could have applied for a Conversion Policy, the amount of Life Insurance the Employee could have converted will be paid as the death benefit, even if the Employee had not applied for the Conversion Policy.

DEPENDENT VOLUNTARY TERM LIFE INSURANCE BENEFITS

IN-70054-07 EM DL.PORT 19

The amount of the Dependent Voluntary Term Life Insurance Benefit is shown on the Schedule of Benefits. In no event will the Dependent Term Life Insurance Benefit exceed 50% of the amount of the Employee Life Insurance amount. BENEFITS The applicable Dependent Voluntary Term Life Insurance Benefit will be paid to the beneficiary subject to the terms below: • The covered Dependent dies while coverage is in force; and • Proof of death is received that the Dependent's death occurred while insured for this benefit. Dependent Voluntary Term Life Insurance has no cash surrender or loan values. REDUCTION FOR AGE Reduction percentage(s) and reduction age(s), if any, are shown on the Schedule of Benefits. If Your death occurs on or after a reduction age, the amount of payment will be reduced by the corresponding reduction percentage shown. A reduction in benefits due to age is effective on the first day of the calendar month following the date You attain that age. BENEFICIARY The Employee will be paid the applicable amount of Dependent Voluntary Term Life Insurance shown on the Schedule of Benefits in the event of death of one of his or her covered Dependents. If the Employee does not survive the Dependent, the applicable Dependent Voluntary Term Life Insurance amount will be payable, at our option, to one or more of the following; • Your parents; • Your children; • Your brothers and sisters; or • Your estate. We will rely upon an affidavit to determine benefit payment, unless We receive written notice of valid claim before payment is made pursuant to the affidavit will release Us from further liability. Any payment made by Us in good faith will fully discharge Us to the extent of such payment. Any amount payable to a minor will be paid to the minor's legal guardian.

DEPENDENT VOLUNTARY TERM LIFE INSURANCE BENEFITS (continued)


NOTICE OF DEATH No payment will be made unless We receive written proof of death. In order to receive benefits, written notice of death must be furnished to Us within 12 months after the date of death. If a death claim is filed more than 12 months after the date of death, We must have proof that it was not possible for the claim to be filed within 12 months. LIMITED BENEFITS FOR SELF-INDUCED SICKNESS, SUICIDE OR SELF-INFLICTED BODILY INJURY In the event of death caused by self-induced Sickness, suicide or self-inflicted Bodily Injury, whether sane or insane, within the first year of Your effective date of Dependent Voluntary Life coverage under the Employer's plan, benefits will be limited to the premium paid for this Dependent Voluntary Life insurance. LIMITATIONS Voluntary Life Benefits do not cover loss resulting from: • Self-induced Sickness, attempted suicide or intentionally self-inflicted Bodily Injury, whether sane

or insane within the first year of Your effective date of Dependent Voluntary Term Life coverage under the Employer's plan. Benefits will be limited to the premium paid for this Dependent Voluntary Term Life Insurance;


inhaled as prescribed or administered by a Qualified Practitioner within the first year of Your effective date of Dependent Voluntary Term Life coverage under the Employer's plan. Benefits will be limited to the premium paid for this Dependent Voluntary Term Life Insurance;


licensed passenger airline; • Commission or attempt to commit a civil or criminal battery or felony; • Service in any armed forces except if You are in temporary active duty as a reservist for military



− Any act of armed conflict, or any conflict involving armed forces of any authority; or • Participation in a riot, rebellion or insurrection. Participation means taking an active part in common with others. Riot means any use or threat to use force or violence by three or more persons without the authority of law.

DEPENDENT VOLUNTARY TERM LIFE INSURANCE BENEFITS (continued)


DEPENDENT LIFE INSURANCE CONVERSION PRIVILEGE The Dependent is entitled to apply for a Conversion Policy of Life Insurance if: • Insurance which has been continued under this section of the Employer's Policy terminates; • The Employer terminates the Portability Provision; • The Employee dies; or • The Dependent ceases to qualify as a Dependent or reaches the limiting age. The amount the Dependent is entitled to apply for is the lesser of: • The amount of Dependent Voluntary Term Life Insurance that is terminating, LESS the amount of

any Life Insurance for which he or she becomes eligible under any group coverage within 31 days after such termination; or

• $10,000. CONVERSION POLICY The Conversion Policy is issued without evidence of insurability. The Employee, on behalf of the covered Dependent, must apply for and pay the first premium within 31 days of the termination of the Dependent's coverage under the Group Plan. The Conversion Policy will be effective on the 32nd day following such termination. It will be issued on any one of the policy forms, except term insurance, then being issued by Us to individuals of the same age. Premiums for the Conversion Policy will be based on Our current rate for the form, amount of insurance and the Dependent's age on the date of issue of the Conversion Policy. NOTICE OF RIGHT TO CONVERT If the covered Dependent has not received notice of his or her right to convert to an individual policy within 15 days before the end of the 31 day conversion period, the covered Dependent will have an additional 15 days from the date the covered Dependent is notified in which to convert; provided, however, that the life insurance coverage under the Policy will not extend beyond the 31st day after termination of the covered Dependent's coverage, nor will the covered Dependent's right to convert be extended more than 60 days beyond the covered Dependent's initial 31 day conversion period. DEATH DURING CONVERSION PERIOD If the Dependent dies during the 31 day period that he or she could have applied for a Conversion Policy, the amount of Life Insurance the Dependent could have converted will be paid as the death benefit, even if the Dependent had not applied for the Conversion Policy.

DISCOUNT DISCLOSURE

Discount 22

From time to time, We may offer or provide access to discount programs to persons who become insureds. In addition, We may arrange for third party service providers such as pharmacies, optometrists, dentists and alternative medicine providers, to provide discounts on goods and services to persons who become insureds. Some of these third party service providers may make payments to Us when insureds take advantage of these discount programs. These payments offset the cost to Us of making these programs available and may help reduce the costs of Your plan administration. Although We have arranged for third parties to offer discounts on these goods and services, these discount programs are not insured benefits under this Policy. The third party service providers are solely responsible to insureds for the provision of any such goods and/or services. We are not responsible for any such goods and/or services, nor are We liable if vendors refuse to honor such discounts. Further, We are not liable to insureds for the negligent provision of such goods and/or services by third party service providers. Discount programs may not be available to persons who "opt out" of marketing communications and where otherwise restricted by law.

Toll Free: 800-558-4444 1100 Employers Blvd. Green Bay,WI 54344 www.humana.com

INSURED BY

HUMANA INSURANCE COMPANY

Form 1643 IN 12/16

NOTICE OF PROTECTION PROVIDED BY THE INDIANA LIFE AND

HEALTH INSURANCE GUARANTY ASSOCIATION

This notice provides a brief summary of the Indiana Life and Health Insurance Guaranty Association (“ILGHIGA”) and the protection it provides for policyholders. ILHIGA was established to provide protection to policyholders in unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations. If this should happen, ILHIGA will typically arrange to continue coverage and pay claims, in accordance with Indiana law, with funding from assessments paid by other insurance companies. Basic Protections Currently Provided by ILHIGA Generally, an individual is covered by ILHIGA if the insurer was a member of the ILHIGA and the Individual lives in Indiana at the time the insurer is ordered into liquidation with a finding of insolvency. The coverage limits below apply only for companies placed in rehabilitation or liquidation on or after January 1, 2013. Life Insurance

• $300,000 in death benefits • $100,000 in cash surrender or withdrawal values

Health Insurance

• $500,000 in basic hospital, medical and surgical or major medical insurance benefits • $300,000 in disability and long term care insurance • $100,000 in other types of health insurance

Annuities

• $250,000 in present value of annuity benefits (including cash surrender or withdrawal values) • $5,000,000 for covered unallocated annuities

The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000. Special rules may apply with regard to basic hospital, medical and surgical or major medical insurance benefits. The protections listed above apply only to the extent that benefits are payable under covered Policy(s). In no event will the ILHIGA provide benefits greater than those given in the life, annuity, or health insurance policy or contract. The statutory limits on ILHIGA coverage have changed over the years and coverage in prior years may not be the same as that set forth in this notice. Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or variable annuity contract. To learn more about the protections provided by ILHIGA, please visit ILHIGA website at www.inlifega.org or contact: Indiana Life and Health Insurance Indiana Department of Insurance Guaranty Association 311 West Washington Street, Suite 103 3502 Woodview Trace Suite 100 Indianapolis, IN 46204 Indianapolis, IN 46268 317-232-2385 317-636-8204 The policy or contract that this notice accompanies might not be fully covered by ILHIGA and even if coverage is currently provided, coverage is (a) subject to substantial limitations and exclusions

Form 1643 IN 12/16

(some of which are described above), (b) generally conditioned on continued residence in Indiana, and (c) subject to possible change as a result of future amendments to Indiana law and court decisions. Complaints to allege a violation of any provision of the Indiana Life and Health Insurance Guaranty Association Act must be filed with the Indiana Department of Insurance, 311 W. Washington Street, Suite 103, Indianapolis, IN 46204; (telephone) 317-232-2385. Insurance companies and agents are not allowed by Indiana law to use the existence of ILHIGA or its coverage to encourage you to purchase any form of insurance (IC 27-89-8-18(a)). When selecting an insurance company, you should not rely on ILHIGA coverage. If there is any inconsistency between this notice and Indiana law, Indiana law will control. Questions regarding the financial condition of a company or your life, health insurance policy or annuity should be directed to your insurance company or agent.

NOTICE TO POLICYHOLDERS REGARDING FILING COMPLAINTS WITH THE DEPARTMENT OF INSURANCE

Questions regarding your policy or coverage should be directed to: Humana Insurance Company 1-800-558-4444 If you (a) need the assistance of the governmental agency that regulates insurance; or (b) have a complain you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email: State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, IN 46204 Consumer Hotline: 1-800-622-4461; or 1-317-232-2395 Complaints can be filed electronically at www.in.gov/idoi.

Notices

The following pages contain important information about Humana's claims procedures and certain federal laws. There may be differences between the Certificate of Insurance and this Notice packet. There may also be differences between this notice packet and state law. The Plan participant is eligible for the rights more beneficial to the participant. This section includes notices about: Claims and Appeal Procedures Federal Legislation Claims Procedures Appeals of Adverse Determinations

Your Rights Under ERISA Privacy and Confidentiality Statement Discrimination Notice

LIFE INSURANCE WAVIER OF PREMIUM AND SHORT TERM DISABILITY CLAIMS PROCEDURES

CLAIMS PROCEDURES Definitions Humana: Humana Insurance Company Claimant: A covered person (or authorized representative) who files a claim. Submitting a Claim This section describes how a Claimant files a claim for plan benefits. A request for a waiver of Life Insurance premium due to a total disability will be treated as a claim. A claim must be filed in writing and delivered by mail, postage prepaid, by FAX or e-mail. Claims will be not be deemed submitted for purposes of these procedures unless and until received at the correct address. Claims submissions must be in a format acceptable to Humana and compliant with any legal requirements. Claims not submitted in accordance with the requirements of applicable federal law respecting privacy of protected health information and/or electronic claims standards will not be accepted by Humana. Claims submissions must be timely. Claims must be filed as soon as reasonably possible, and in no event later than the period of time described in the benefit plan document. Claims submissions must be submitted on the claims form provided by Humana and available from your employer. The claim form must be complete. Authorized Representatives A covered person may designate an authorized representative to act on his or her behalf in pursuing a benefit claim or appeal. The authorization must be in writing and authorize disclosure of health information. If a document is not sufficient to constitute designation of an authorized representative, as determined by Humana, the plan will not consider a designation to have been made. An assignment of benefits does not constitute designation of an authorized representative. Covered persons should carefully consider whether to designate an authorized representative. Circumstances may arise under which an authorized representative may make decisions independent of the covered person, such as whether and how to appeal a claim denial. Claims Decisions Humana will provide notice of a favorable or adverse determination within a reasonable time but no later than 45 days after the plan receives the claim.

This period may be extended an additional 30 days, if Humana determines the extension is necessary due to matters beyond the plan’s control. Before the end of the initial 45-day period, Humana will notify the affected Claimant of the extension, the circumstances requiring the extension and the date by which the plan expects to make a decision. The review period may be extended for another 30 days, if before the end of the first 30-day extension, the plan determines a second extension is necessary due to matters beyond the plan’s control. Before the end of the first 30-day extension, Humana will notify the affected Claimant of the additional extension, the circumstances requiring the extension and the date by which the plan expects to make a decision. If the reason for the extension is because Humana does not have enough information to decide the claim, the notice of extension will describe the required information, and the Claimant will have at least 45 days from the date the notice is received to provide the specified information. Humana will make a decision on the earlier of the date on which the Claimant responds or the expiration of the time allowed for submission of the requested information. Initial Denial Notices Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e-mail, as appropriate, within the time frames noted above. A claims denial notice will convey the specific reason for the adverse determination and the specific plan provisions upon which the determination is based. The notice will also include a description of any additional information necessary to perfect the claim and an explanation of why such information is necessary. The notice will disclose if any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of the rule, protocol or similar criterion will be provided to Claimants, free of charge, upon request. APPEALS OF ADVERSE DETERMINATIONS A Claimant must appeal an adverse determination within 180 days after receiving written notice of the denial (or partial denial). An appeal may be made by a Claimant by means of written application to Humana, in person, or by mail, postage prepaid. Determination of appeals of denied claims will be conducted promptly, will not defer to the initial determination and will not be made by the person who made the initial adverse claim determination or a subordinate of that person. On appeal, a Claimant may review pertinent documents and may submit issues and comments in writing. A Claimant on appeal may, upon request, discover the identity of medical or vocational experts whose advice was obtained on behalf of the plan in connection with the adverse determination being appealed, as permitted under applicable law. If the claims denial is based in whole, or in part, upon a medical judgment, the person deciding the appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The consulting health care professional will not be the same person who decided the initial appeal or a subordinate of that person.

Time Periods for Decisions on Appeal Appeals of claims denials will be decided and notice provided within 45 days after Humana receives the appeal request. This period may be extended an additional 45 days, if Humana determines the extension is necessary due to matters beyond the plan's control. Before the end of the initial 45-day period, Humana will notify the affected Claimant of the extension, the circumstances requiring the extension and the date by which the plan expects to make a decision. Appeals Denial Notices Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e-mail, as appropriate, within the time periods noted above. A notice that a claim appeal has been denied will include: • The specific reason or reasons for the adverse determination. • Reference to the specific plan provision upon which the determination is based. • If any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of

the rule, protocol or similar criterion will be provided to the Claimant, free of charge, upon request. • A statement describing any voluntary appeal procedures offered by the plan and the claimant's right

to obtain the information about such procedures, and a statement about the Claimant's right to bring an action under ERISA.

In the event an appealed claim is denied, the Claimant will be entitled to receive without charge reasonable access to and copies of any documents, records or other information that: • Was relied upon in making the determination. • Was submitted, considered or generated in the course of making the benefit determination, without

regard to whether such document, record or other information was relied upon in making the benefit determination.

• Demonstrates compliance with the administrative processes and safeguards required in making the

determination. • Constitutes a statement of plan policy or guidance with respect to the plan concerning the denied

benefit, without regard to whether the statement was relied on in making the benefit determination. EXHAUSTION OF REMEDIES Upon completion of the appeals process under this section, a Claimant will have exhausted his or her administrative remedies under the plan. If Humana fails to complete a claim determination or appeal within the time limits set forth above, the claim shall be deemed to have been denied and the Claimant may proceed to the next level in the review process.

After exhaustion of remedies, a Claimant may pursue any other legal remedies available, which may include bringing civil action under ERISA section 502(a) for judicial review of the plan's determination. Additional information may be available from the local U.S. Department of Labor Office. LEGAL ACTIONS AND LIMITATIONS No lawsuit may be brought with respect to plan benefits until all remedies under the plan have been exhausted. No lawsuit with respect to plan benefits may be brought after the expiration of the applicable limitations period stated in the benefit plan document. If no limitation is stated in the benefit plan document, then no such suit may be brought after the expiration of the applicable limitations under applicable law. YOUR RIGHTS UNDER ERISA Under the Employee Retirement Income Security Act of 1974 (ERISA), all plan participants covered by ERISA are entitled to certain rights and protections, as described below. Notwithstanding anything in the group health plan or group insurance policy, following are a covered person’s minimum rights under ERISA. ERISA requirements do not apply to plans maintained by governmental agencies or churches. Information about the Plan and Benefits Plan participants may: 4. Examine, free of charge, all documents governing the plan. These documents are available in the

plan administrator's office. 5. Obtain, at a reasonable charge, copies of documents governing the plan, including a copy of any

updated summary plan description and a copy of the latest annual report for the plan (Form 5500), if any, by writing to the plan administrator.

6. Obtain, at a reasonable charge, a copy of the latest annual report (Form 5500) for the plan, if any, by writing to the plan administrator.

As a plan participant, you will receive a summary of any material changes made in the plan within 210 days after the end of the plan year in which the changes are made unless the change is a material reduction in covered services or benefits, in which case you will receive a summary of the material reduction within 60 days after the date of its adoption. If the plan is required to file a summary annual financial report, you will receive a copy from the plan administrator. Responsibilities of Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the plan. These people, called 'fiduciaries" of the plan, have a duty to act prudently and in the interest of plan participants and beneficiaries. No one, including an employer, may discharge or otherwise discriminate against a plan participant in any way to prevent the participant from obtaining a benefit to which the participant is otherwise entitled under the plan or from exercising ERISA rights.

Claims Determinations If a claim for a plan benefit is denied or disregarded, in whole or in part, participants have the right to know why this was done, to obtain copies of documents relating to the decision without charge and to appeal any denial within certain time schedules. Enforce Your Rights Under ERISA, there are steps participants may take to enforce the above rights. For instance, if a participant requests a copy of plan documents does not receive them within 30 days, the participant may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $ 110 a day until the participant receives the materials, unless the materials were not sent because of reasons beyond the control of the plan administrator. If a claim for benefits is denied or disregarded, in whole or in part, the participant may file suit in a state or Federal court. In addition, if the participant disagrees with the plan's decision, or lack thereof, concerning the qualified status of a domestic relations order or a medical child support order, the participant may file suit in Federal court. If plan fiduciaries misuse the plan's money, or if participants are discriminated against for asserting their rights, they may seek assistance from the U.S. Department of Labor, or may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If the participant is successful, the court may order the person sued to pay costs and fees. If the participant loses, the court may order the participant to pay the costs and fees. Assistance with Questions Contact the group health plan human resources department or the plan administrator with questions about the plan. Contact the nearest area office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210 with questions about ERISA rights. Call the publications hotline of the Employee Benefits Security Administration to obtain publications about ERISA rights. PRIVACY AND CONFIDENTIALITY STATEMENT We understand the importance of keeping your personal and health information private (PHI). PHI includes both medical information and individually identifiable information, such as your name, address, telephone number or social security number. We are required by applicable federal and state law to maintain the privacy of your PHI. Under both law and our policies, we have a responsibility to protect the privacy of your PHI. We: • Protect your privacy by limiting who may see your PHI; • Limit how we may use or disclose your PHI; • Inform you of our legal duties with respect to your PHI; • Explain our privacy policies; and • Strictly adhere to the policies currently in effect. We reserve the right to change our privacy practices at any time, as allowed by applicable law, rules and regulations. We reserve the right to make changes in our privacy practices for all PHI that we maintain, including information we created or received before we made the changes. When we make a significant change in our privacy practices, we will send notice to our health plan subscribers. For more information about our privacy practices, please contact us.

As a covered person, we may use and disclose you PHI, without your consent/authorization, in the following ways: Treatment: we may disclose your PHI to a health care practitioner, a hospital or other entity which asks for it in order for you to receive medical treatment. Payment: we may use and disclose your PHI to pay claims for covered services provided to you by health care practitioners, hospitals or other entities. We may use and disclose your PHI to conduct other health care operations activities. It has always been our goal to ensure the protection and integrity of your personal and health information. Therefore, we will notify you of any potential situations where your identification would be used for reasons other than treatment, payment and health plan operations.

Discrimination is Against the Law

Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Humana Inc. and its subsidiaries do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Humana Inc. and its subsidiaries provide: • Free auxiliary aids and services, such as qualified sign language interpreters, video remote

interpretation, and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate.

• Free language services to people whose primary language is not English when those services are

necessary to provide meaningful access, such as translated documents or oral interpretation. If you need these services, call 1-855-448-6982 or, if you use a TTY, call 711. If you believe that Humana Inc. and its subsidiaries have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Discrimination Grievances P.O. Box 14618 Lexington, KY 40512-4618 If you need help filing a grievance, call 1-855-448-6982 or if you use a TTY, call 711. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

http://www.hhs.gov/ocr/office/file/index.html

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